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DOI: 10.1148/radiol.2211010017
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(Radiology. 2001;221:64-69.)
© RSNA, 2001

Pediatric Imaging

Coats Disease: Smaller Volume of the Affected Globe1

Paolo Galluzzi, MD, Carlo Venturi, MD, Alfonso Cerase, MD, Ignazio Maria Vallone, MD, Sandra Bracco, MD, Anna Maria Bardelli, MD, Theodora Hadjistilianou, MD, Paola Gennari, MD, Lucia Monti, MD and Giuseppe Filosomi, MD

1 From the Unit of Diagnostic and Therapeutic Neuroradiology, Azienda Ospedaliera Senese, and the InterDepartmental Center of Magnetic Resonance (P. Galluzzi, C.V., A.C., I.M.V., S.B., P. Gennari, L.M., G.F.), the Department of Pediatric Ophthalmology (A.M.B.), and the Center for Intraocular Tumors (T.H.), University of Siena, Policlinico "Le Scotte," Viale Mario Bracci 1, 53100 Siena, Italy. From the 2000 RSNA scientific assembly. Received November 27, 2000; revision requested January 4, 2001; revision received March 15; accepted April 6. Address correspondence to P. Galluzzi (e-mail: neurorad@ao-siena.toscana.it).


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
PURPOSE: To determine whether a significant smaller volume of the affected globe, compared with that of the normal globe, is an additional feature of Coats disease.

MATERIALS AND METHODS: Ocular globe volume was assessed in 13 children (11 boys, two girls; age range, 0.6–14 years; mean age, 4.1 years) with Coats disease and in 18 (eight boys, 10 girls; age range, 0.5–12 years; mean age, 3.6 years) with unilateral retinoblastoma. Orbital computed tomographic scans were available for all children; magnetic resonance images were available for 11 children—seven with Coats disease and four with retinoblastoma. For volume estimation, anteroposterior and equatorial diameters of ocular globes were measured. Statistical analysis was conducted with univariate and multivariate methods.

RESULTS: In children with Coats disease, the mean volume of the affected globe was 4,877.03 mm3 (range, 2,951.47–6,284.70 mm3) and that of the normal globe, 6,018.00 mm3 (range, 4,062.32–7,509.26 mm3). In children with retinoblastoma, the mean volume of the affected globe was 4,557.06 mm3 (range, 1,612.01–7,463.00 mm3) and that of the normal globe, 4,402.11 mm3 (range, 1,360.46– 7,463.00 mm3). The Coats disease population had a significantly smaller volume of the affected globe (z = -3.1009; P = .002); the retinoblastoma population did not have a statistically significant trend toward a bigger affected globe volume (z = -1.7064; P = .088). The difference between the affected globe volume and the normal globe volume in children with Coats disease was the only significant independent variable (P = .005).

CONCLUSION: A significantly smaller volume of the affected globe is an additional feature of Coats disease.

Index terms: Eye, abnormalities, 2245.372, 2245.69, 2245.892 • Eye, CT, 224.1211 • Eye, diseases, 2245.69 • Eye, MR, 224.121411, 224.12143 • Eye, neoplasms, 2245.372 • Retina, 2245.372, 2245.69, 2245.892


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Coats disease is a rare congenital, but nonfamilial, idiopathic vascular developmental disease of the retina, primarily caused by a defect at the endothelial cell level of the blood-retinal barrier, resulting in leakage of fluid into the vessel wall and perivascularly. Weakening of the vessel wall structure leads to the formation of telangiectases, aneurysms, and progressive intraretinal and subretinal leakage, resulting in exudative retinal detachment (1–6). Coats disease is unilateral in 80%–90% of patients, affecting 69%–85% of males, and is isolated in most cases. The most frequent age at diagnosis ranges from 3 to 9 years. Leukokoria and strabismus are the most common signs (2–14). Progression to total retinal detachment, blindness, phthisis bulbi, and painful neovascular glaucoma occur in slightly more than half of the untreated patients (12,13). Spontaneous remission rarely occurs (15).

The diagnosis is generally made by means of indirect ophthalmoscopy, supplemented with A- and B-mode ultrasonography (US), and/or intravenous fluorescein angiography in selected patients (8,11,13). The main problem is to differentiate advanced Coats disease from retinoblastoma because both diseases may present with nonrhegmatogenous retinal detachment, telangiectases, and subretinal collections (6,16–20). The differential diagnosis depends on the age at presentation, including an extensive list of primary and secondary, benign and malignant retinal detachment–related lesions (Table 1).


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  		TABLE 1. Differential Diagnosis of Coats Disease

 
Retinoblastoma is a highly malignant tumor arising from retinal neuroectodermal cells, with the average age at presentation ranging from 13 to 18 months. Retinoblastoma confined to the eye has a high 5-year survival rate (>88% in developed countries), but spread beyond the eye results in a dismal prognosis (21). Thus, misdiagnosis of retinoblastoma as advanced Coats disease delays the appropriate therapeutic decisions, increasing the risk of extraocular spread and death (21). When clinical diagnosis is uncertain, computed tomography (CT) and magnetic resonance (MR) imaging achieve greater diagnostic accuracy (11,14,22,23–31); however, exceptions to the typical imaging features are seen in both Coats disease and retinoblastoma (6,8,9,26,32,33). Patients with advanced Coats disease may still undergo enucleation because retinoblastoma cannot be ruled out (10,16).

Observations in our clinical practice and a review of some published CT and/or MR images (22,28) led us to note that the volume of the affected globe (AG) in patients with Coats disease may be smaller than the volume of the contralateral unaffected eye. This finding has been mentioned in a prior report (23). The purpose of our study was to determine whether a statistically significant smaller volume of the AG, compared with that of the normal globe, may be an additional feature of Coats disease.


   MATERIALS AND METHODS
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
RESULTS
 DISCUSSION
 REFERENCES
 
We performed a retrospective review of CT scans and MR images of the eyes in 13 children with Coats disease and 18 children with unilateral retinoblastoma. The 13 children with Coats disease were all affected by this disease and have been examined at our institution between 1985 and 2000. The 18 children with retinoblastoma are from a population of approximately 100 patients with retinoblastoma who were examined at our institution during the same time. The 31 children have been enrolled because of the availability of images on digital support systems for pertinent measurements.

Clinical data were collected from inpatient and outpatient medical records at our institution and included sex, age, affected eye, stage of the disease at presentation, resulting from indirect ophthalmoscopy supplemented with intravenous fluorescein angiography and/or US in selected cases, surgery, and histologic examination, if performed. At our institution, institutional review board approval and informed consent are not required for retrospective review of medical records.

At the time of presentation, of the 13 children with Coats disease, seven underwent nonenhanced and contrast material–enhanced CT of the orbits, one underwent nonenhanced MR imaging, five underwent nonenhanced CT and nonenhanced and gadolinium-enhanced MR imaging, and one underwent nonenhanced and gadolinium-enhanced MR imaging. Of the 18 children with retinoblastoma, 14 underwent nonenhanced and contrast-enhanced CT of the orbits, and four underwent nonenhanced CT and nonenhanced and gadolinium-enhanced MR imaging. In all cases, parents had given informed consent for these diagnostic imaging examinations.

In the 13 children with Coats disease, clinical staging was based on the following classification system (3): stage 1, evidence of focal exudates; stage 2, massive intraretinal exudation; stage 3, partial exudative retinal detachment; stage 4, total retinal detachment; and stage 5, complications (rubeosis iridis, neovascular glaucoma, cataract[s], uveitis, or phthisis bulbi) secondary to chronic retinal detachment at indirect ophthalmoscopy. Clinical follow-up ranged from 1 to 11 years.

Serial 1.5–3-mm-thick transverse CT sections were available for this study, as well as serial nonenhanced T1-weighted spin-echo, fast and turbo T2-weighted spin-echo, and transverse gadolinium-enhanced T1-weighted spin-echo 3-mm-thick sections obtained at MR imaging with 0.5-T and 1.5-T systems (Gyroscan ACSNT 5 and 15; Philips Medical Systems, Best, the Netherlands) by using surface and/or head coils.

One neuroradiologist (P. Galluzzi), blinded to the clinical diagnosis, evaluated the CT scans for intraocular attenuation, compared with the normal contralateral vitreous, the presence of intraocular calcifications and/or mass, and the pattern of contrast enhancement and evaluated the MR images for the signal intensity of intraocular lesions and/or subretinal collections, compared with the unaffected vitreous, and the pattern of gadolinium enhancement. In addition, at the CT and MR monitors, he measured anteroposterior and equatorial diameters of the 62 globes on sections showing the largest transverse plane of the eyeball, which usually shows the maximum size of the lens (34).

The anteroposterior diameter was determined as the distance from the posterior corneal surface to the posterior wall of the choroid, including the anterior chamber depth, lens thickness, and vitreous length. The equatorial diameter was obtained at the maximum transverse width (34,35). These measurements were made on both CT sections and on T1-weighted, T2-weighted, and gadolinium-enhanced T1-weighted transverse MR images (Figs 1, 2). The largest diameters were used to estimate the volume with the following formula: [(anteroposterior diameter + equatorial diameter/2)/2]3 · (4/3{pi}). Microphthalmos was defined as an eye with a volume of at least 2 SDs below the mean for age-similar controls (36); comparison was made with published standards (34).



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  		Figure 1. Transverse gadolinium-enhanced T1-weighted spin-echo MR image in a 13-month-old boy with Coats disease of the right eye (anteroposterior diameter, 20.1 mm; equatorial diameter, 20.7 mm). Anteroposterior and equatorial diameters of the normal left globe were 22.6 mm and 22.8 mm, respectively.

 


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  		Figure 2. Transverse T2-weighted high-resolution turbo spin-echo MR image in a 9-month-old female infant with retinoblastoma of the right eye (anteroposterior diameter, 18.8 mm; equatorial diameter, 19.5 mm). Anteroposterior and equatorial diameters of the normal left globe were 18.5 mm and 18.9 mm, respectively.

 
Statistical analysis comparing the volumes of the affected and the normal globes was conducted with univariate and multivariate methods, including the Wilcoxon paired-sample test and logistic regression model with receiver operating characteristic (ROC) curve analysis by using the binary dependent (disease, yes/no) and independent (gender, age in months, side of the AG, and the difference between the AG volume and the normal globe volume) variables.


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
DISCUSSION
 REFERENCES
 
The 13 children (two girls and 11 boys) with Coats disease (Table 2) ranged in age from 7 months to 14 years (mean age, 4.1 years). The right eye was affected in six patients and the left in seven. Stage 5 was the most frequent (n = 5) stage of disease, followed by stages 4 (n = 3) and 3 (n = 3), and stage 1 (n = 2). CT and/or MR findings varied with the stage of progression of the disease.


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  		TABLE 2. Demographics and Diameters of Ocular Globes in Patients with Coats Disease

 
In stage 1, the CT finding was normal in patient 2, and MR imaging showed a subtle retinal thickening consistent with focal exudates at ophthalmoscopy in patient 1. In stage 3, CT showed a shallow curvilinear partial retinal detachment in patient 5, MR imaging showed a larger partial retinal detachment, with subretinal fluid of high signal intensity on both nonenhanced T1- and T2-weighted images and mild enhancement of the detached leaves of sensory retina after gadolinium administration in patients 3 and 4. In stages 4 and 5, imaging findings were typical of advanced disease and included a homogeneously diffuse increased attenuation of the AG, without intraocular calcifications or an intraocular enhancing mass at CT (patients 6–13), subretinal fluid showing high signal intensity on both nonenhanced T1- and T2-weighted images, and low to marked linear enhancement of the detached leaves of sensory retina on gadolinium-enhanced MR images (patients 10–13).

None of the eyes were microphthalmic. The mean volume of the AG was 4,877.03 mm3 (range, 2,951.47–6,284.70 mm3; SD, 793.50) and of the contralateral normal globe, 6,018.00 mm3 (range, 4,062.32–7,509.26 mm3; SD, 1,005.60) (Fig 1). Four patients (patients 10–13) underwent enucleation because of the development of painful glaucoma; histologic examination confirmed Coats disease.

The 18 children (eight boys and 10 girls) with unilateral retinoblastoma (Table 3) ranged in age from 6 months to 12 years (mean, 3.6 years). The right eye was affected in eight children and the left eye in 10. In all children, MR images and/or CT scans were typical for the tumor (22, 23,25,29,31). CT scans showed a mildly to moderately hyperattenuating intraocular mass with variable calcifications and moderate to marked enhancement after the administration of the contrast material, and MR images showed an intraocular lesion slightly to moderately hyperintense compared with the normal vitreous on T1-weighted images and darker on T2-weighted images, with moderate to marked enhancement after gadolinium administration. None of the eyes were microphthalmic. The mean volume of the AG was 4,557.06 mm3 (range, 1,612.01–7,463.00 mm3; SD, 1,981.00) and of the normal globe, 4,402.11 mm3 (range, 1,360.46–7,463.00 mm3; SD, 1,912.19) (Fig 2). All of these patients underwent enucleation. At histologic examination, 11 retinoblastomas were endophytic, one was exophytic, and six showed both endophytic and exophytic components.


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  		TABLE 3. Demographics and Diameters of Ocular Globes in Patients with Retinoblastoma

 
In the population with Coats disease, the Wilcoxon paired-sample test analysis showed a significantly smaller globe volume of the affected eye, compared with the normal eye (z = -3.1009; two-tailed P = .002) and in the retinoblastoma population, a not statistically significant trend toward a bigger size of the affected eye, compared with the normal eye (z = -1.7064; two-tailed P = .088). By using a backward elimination scheme, none of the independent variables were significant, except the difference between the AG volume and the normal globe volume in patients with Coats disease (P = .005). By using this difference, the ROC curve for predicting Coats disease was 0.9487. Sensitivity and specificity were 92% and 94%, respectively, if a cutoff of approximately -360 to -430 had been defined for this difference.


   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
REFERENCES
 
In Coats disease, blood-retinal barrier impairment results in increasing amounts of yellowish intraretinal and subretinal exudate composed of blood components rich in cholesterol crystals, cholesterol- and pigment-laden macrophages, few erythrocytes, and minimal hemosiderin (6,7). Usually no distinct intraocular mass is seen. However, in as many as 20% of the patients, a fibrous submacular nodule may develop, probably from exuberant proliferation and metaplasia of the retinal pigment epithelium; these nodules are rarely calcified or ossified (6,9). Neovascularization of the retina or choroid may develop and may hemorrhage. Chronic massive retinal detachment may lead to involvement of the anterior segment, including iris neovascularization, with closure of the anterior chamber angle, iris atrophy, and lens opacification (6,8).

When ocular refractory media are opaque, clinical examination and US are limited. It may be difficult to differentiate advanced Coats disease from benign and malignant conditions with similar findings; however, the main problem remains the differentiation from retinoblastoma. Patients with retinoblastoma must not incur delay in receiving appropriate treatment (21). Prior intraocular surgery performed in patients with retinoblastoma may accelerate tumor seeding (8,21,37,38), and a secure diagnosis prevents unnecessary enucleation in cases with a benign disease (12,13). However, making the distinction between advanced Coats disease and retinoblastoma still remains a great challenge in clinical ophthalmology.

Several exceptions to the usual age at presentation have been reported (8,12) in both diseases. As many as 40% of the patients with advanced Coats disease present before the age of 2 years (8), such as occurred in six of the 13 patients in our study. Clinically, as many as 58% of the patients with Coats disease may undergo unnecessary enucleation (6,19), and as many as 16% of the patients with retinoblastoma may be misdiagnosed as having Coats disease (20). Notably, diffusely infiltrating retinoblastoma usually occurs outside the typical age group, shows atypical ophthalmoscopic features simulating inflammatory or hemorrhagic conditions, and often lacks calcification (10,22).

US does not improve the diagnosis in eyes with diffuse vitreous infiltration, poorly calcified masses, and complex interfaces. The analysis of aqueous humor for the levels of various substances is not as useful at present (8,39). Fine-needle subretinal aspiration biopsy is controversial because of the substantial risk of procedure-related tumor seeding (8,37). When the clinical diagnosis is uncertain, CT and/or MR imaging are required. Because intraocular calcifications in children younger than 3 years should be considered a manifestation of retinoblastoma, with the exceptions of children with microphthalmos and colobomatous cyst or choroidal osteoma and immunocompromised children with cytomegaloviral chorioretinitis (31), the main indication for CT is the search for intraocular calcifications (13,19,22–24,28).

The imaging findings of Coats disease vary with the disease progression (11,22, 25,27–29). In the early stages, imaging yields little or no information. In the advanced stages, the diagnosis is favored by partial or total retinal detachment, absence of an intraocular mass, homogeneously diffuse intraocular increased attenuation when compared with the vitreous of the unaffected eye, absence of intraocular calcifications on CT scans, and subretinal fluid hyperintense with all pulse sequences at MR imaging. After contrast administration, Coats disease may show enhancement along the leaves of the detached sensory retina and at the sites where retina inserts, while retinoblastoma enhances in a masslike fashion; these findings are obviously better shown on gadolinium-enhanced MR images with or without the fat-suppression technique (23,26,27,29).

Proton MR spectroscopy has been advocated for providing specific information by revealing a large lipid peak in the subretinal collection in Coats disease (30). Nowadays, patients with Coats disease generally undergo enucleation only when painful neovascular glaucoma occurs in a blind eye (13,29), such as occurred in four of the 13 patients in our study. However, and unfortunately, exceptions to the typical CT and MR features exist in both Coats disease and retinoblastoma, still resulting in unnecessary enucleation for equivocal or conflicting findings (10,16).

A retrolental enhancing gliotic mass simulating nodular retinoblastoma can occur in extreme cases of advanced Coats disease (33). The rare diffuse infiltrating retinoblastoma may not show nodularity with any imaging studies (22). On CT scans, as many as 5% of the retinoblastomas have no evidence of calcifications, especially diffuse infiltrating retinoblastomas (15,22). Furthermore, occasional reports of calcifications in Coats disease have been well documented (6,9,28,32). It has been reported (26,27) that MR images do not depict retinoblastomas with a thickness equal or less than 2 mm, even if a surface coil is used and gadolinium-enhanced fat-suppressed T1-weighted images are obtained. In the chronic stages of Coats disease, the MR signal intensity of subretinal fluid may become heterogeneous because of the combination of cholesterol crystals, hemorrhage, material positive for p-aminosalicylic acid, and scarring (8,11,14).

Because diagnosis is crucial if the necessary treatment is to be provided, specific diagnostic signs are of great value to clinicians, and specific imaging changes must be used in the best way. In our study, only the AGs of patients with Coats disease had a statistically significantly smaller volume when compared with those of the unaffected eyes. However, because of the limited sample, a larger more definitive study would be necessary to properly define the optimal cutoff of the differences between the AG volume and the normal globe volume. Although smaller size of the AG has been reported (23) in patients with Coats disease, to the best of our knowledge, this finding has never been described as statistically significant.

Haik (8) came to other conclusions by using CT measurements of the transverse length of both eyes in 19 patients with advanced Coats disease; 15 patients had a globe of normal size, two patients had slightly enlarged globes, and two patients had microphthalmic globes. This difference may be explained by the fact that, despite being slightly ellipsoidal, the ocular globe has been generally assumed to be spherical for volume estimation, because the error introduced is likely to be small (34,40). Furthermore, the globe size has generally been estimated with the measurement of only one of the globe diameters (8,34,41).

We evaluated the globe volume by measuring both the anteroposterior and equatorial diameters. The vertical diameter has been demonstrated to be equal to the anteroposterior diameter in emmetropic, hyperopic, and myopic eyes; thus, it is not necessary to measure the globe volume, annulling the need for coronal images (35). Three-dimensional high-spatial-resolution phased-array MR imaging may result in further improvement in eyeball volumetry (42).

The variability in the size of orbital structures from one person to another is large, but differences between the two sides in a normal population are small (43,44). Ocular globe volume is substantially influenced by age and sex (34, 45,46). A substantial rapid growth occurs in utero and until 18 months of age, followed by a phase of slower growth (45). Ocular globe almost doubles its volume from 3 cm3 at birth to approximately 6 cm3 at 24 months of age in both sexes. A 3-cm3 increment is noted from 2 to 18–30 years of age. At 18–30 years of age, the peak of 9–10 cm3 is reached. Reductions in ocular globe volume occur at an older age (34,45,46). The ocular globe volume is slightly larger in boys than in girls during the entire growth period; this difference remains relatively constant throughout the entire life (34,44). In our study, the relative larger size of the globes in the Coats disease population may be explained by the prevalence of boys and the higher mean age.

Ocular growth is a still incompletely understood complex process governed by a potentially large number of genes and environmental factors (47). Expansion of the vitreous body accounts for 60% of the eye prenatal growth and 90% of the postnatal growth (14,36,41). Vitreous growth in the vertical and equatorial directions proceeds equally until a certain choroidal-scleral thickness is reached. A uniform choroidal-scleral thinning is associated with a posterior vitreal expansion in the myopic eye, and choroidal-scleral thickening seems to control the posterior vitreal expansion in a relatively small hyperopic eye (35).

Some experimental studies in both animals and humans have demonstrated that the globe growth is influenced by the lens thickness in the same way as the growth of the whole orbit is influenced by the presence or absence of the eye (46). Other studies have shown that any tissue in the anterior or posterior eye segments, such as the lens, ciliary body, retina, and primary vitreous, influences the expansion of secondary vitreous by producing regulatory growth factors, thereby affecting ocular growth. Inadequate production of secondary vitreous that results in a microphthalmic eye is seen in some diseases such as coloboma, persistent hyperplastic primary vitreous, and retinal dysplasia (36,48).

In conclusion, our results allow us to postulate that the retinal vascular developmental abnormalities of Coats disease may disturb the release of growth factors that regulate the further development of secondary vitreous, thus resulting in the disturbance of the growth of the AG. We believe additional retrospective and prospective studies are needed to evaluate the significance of the smaller volume of the AG in Coats disease.


   ACKNOWLEDGMENTS
 
We thank Livio Vittori for his technical support, Guido Garosi, MD, for his help in the statistical analysis, and Ombretta Bugiani and Roberto Faleri for providing some important references for the preparation of this article.


   FOOTNOTES
 
Abbreviation: AG = affected globe

Author contributions: Guarantors of integrity of entire study, A.M.B., C.V.; study concepts and design, P. Galluzzi, T.H.; literature research, P. Gennari, A.C., G.F.; clinical studies, A.M.B., T.H., G.F., P. Galluzzi, A.C., L.M., I.M.V., P. Gennari; data acquisition, P. Galluzzi, A.C., S.B.; data analysis/interpretation, P. Galluzzi, I.M.V.; statistical analysis, P. Galluzzi, A.C.; manuscript preparation, P. Galluzzi, A.C.; manuscript definition of intellectual content, P. Galluzzi, A.C., T.H.; manuscript editing, A.C., P.G.; manuscript revision/review and final version approval, A.M.B., C.V.


   REFERENCES
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 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 

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