Lowe's syndrome

For whom is this information intended?
The information contained in this document is intended for use primarily by parents, other members of the family and older children with visual impairment. The information will also be of use to interested health professionals, carers and teachers.

The purpose of each information document
The purpose of the information is to explain:

• The way the eyes and brain normally work to make 'vision'
• The reason why vision may become impaired by a specific condition
• The cause of the condition
• The effects of the condition on the child's vision
• How the condition is diagnosed
• What can be done to help?
• Parents' Support Group

This document is written with the minimum use of medical terms and jargon. It is impossible to avoid all medical terms but where we have used them we have attempted to explain them as clearly as we can. Although the information is intended to describe most aspects of the condition each child is different and there will always be exceptions to the rule. As far as we can determine these pages are true and accurate and have been written in good faith. Inevitably there will be some mistakes. We apologise for this.

What this information is not for
This document is not a substitute for a consultation with a Health Professional and should not to be used as a means of diagnosing a condition. It is not a means to access a 'second opinion' particularly in any medico-legal cases. We hope the information will help you.

After reading the information we hope you will:

• Have a better understanding of the condition
• Know what tests and treatments are normally available
• Know when to seek professional advice
• Be able to discuss the condition in a more informed way
• Make the most of consultations with carers, teachers and health professionals
• Be reassured and more able to cope

Due to staffing limitations we are not able to offer telephone or email advice to parents of children who are not notified with VI Scotland.

Authors
These pages represent the consensus of opinion of many different people who include Parents of Visually Impaired Children, Visually Impaired Children themselves, Community Paediatricians, Ophthalmologists, Educationalists and Psychologists. The main author and person responsible for their content is Dr Andrew Blaikie who is an Ophthalmology Research Fellow with Visual Impairment Scotland and a member of the Royal College of Ophthalmologists.

We are very keen that parents and children feedback to VI Scotland about these information documents.
Visual Impairment, Scotland Scottish Sensory Centre, The University of Edinburgh, Holyrood Road, Edinburgh EH8 8AQ
Telephone Number: 0131 651 6078
Fax Number: 0131 651 6502
Textphone: 0131 651 6067
Email: viscotland@ed.ac.uk

Medical information on Lowe's syndrome

What we see is made in the brain from signals given to it by the eyes
What we see is in fact made in the brain. The brain makes sight from signals given to it by the eyes.

What is the normal structure of the eye?
The eye is made of three parts.

• A light focusing bit at the front (cornea and lens).
• A light sensitive film at the back of the eye (retina).
• A large collection of communication wires to the brain (optic nerve).

A curved window called the cornea first focuses the light. The light then passes through a hole called the pupil. A circle of muscle called the iris surrounds the pupil. The iris is the coloured part of the eye. The light is then focused onto the back of the eye by a lens. Tiny light sensitive patches (photoreceptors) cover the back of the eye. These photoreceptors collect information about the visual world. The covering of photoreceptors at the back of the eye forms a thin film known as the retina. Each photoreceptor sends its signals down very fine wires to the brain. The wires joining each eye to the brain are called the optic nerves. The information then travels to many different special 'vision' parts of the brain. All parts of the brain and eye need to be present and working for us to see normally.

What is Lowe's syndrome?

In Lowe's Syndrome children are born with problems with their:

• Eyes
• Brain and
• Kidneys

The medical word for eye is 'oculo', brain 'cerebro' and kidneys 'renal'. This is why Lowe's dyndrome is also often known as Oculo-cerebro-renal syndrome. A syndrome is a condition where a few different symptoms and signs are typically always seen together. It was first described in the 1950s by a group of doctors lead by Dr Lowe.

The kidneys are important in controlling growth of bones. This is why children with problems with their kidneys can sometimes be shorter than others. Because the eyes, brain and kidneys are typically always affected this often leads to:

• Visual Impairment
• Developmental delay & learning difficulties
• Impaired growth

The condition only affects boys.

What is the cause of Lowe's syndrome?

Lowe's syndrome is caused by an important enzyme not working properly.

What are enzymes?
The body is made up many different parts such as skin, bone, muscle, and the brain. All the different parts of the body are made up of  cells. Cells are tiny factories making materials that the body needs to work and grow. Cells employ 'workers' called enzymes. Enzymes are proteins that help the cells carry out the work they need to do.

Each cell has thousands of different enzymes all working at the same time doing different jobs. Different cells in different parts of the body will use different groups of enzymes. This is because different cells will all have different jobs to do.

Lowe Syndrome occurs when one of these enzymes is ‘broken’ and can no longer work. The enzyme is called phosphatase. It is an important enzyme in the cells of the eyes, brain and kidney.

Why might an enzyme not work?
The body has a 'built-in' plan to make sure all the different enzymes are built correctly. This plan is written in our genes. Genes are a chemical alphabet held in every cell of the body. If there is a misprint in the gene of an enzyme then the enzyme will not work. This often leads to disease. The misprinted gene that causes IP is found on a sex chromosome.

What are sex chromosomes?
Within each tiny cell genes are stored one after the other as long threads. To save space within the cell the threads are folded up tightly into shorter thicker ropes of genes called chromosomes. Almost every cell of the body has exactly the same number and kind of chromosomes. There are 23 different chromosomes. Each chromosome has a copy of itself so that there are 46 in total (23 pairs). One pair of chromosomes are called the sex chromosomes. They are called sex chromosomes because they hold the plan for making an unborn baby grow into a boy or a girl. There are two types of sex chromosomes called X and Y. The letters just describe the shape of the chromosome when seen in fine detail. If a child has an X and a Y sex chromosome then the child will develop into a boy (XY). If the sex chromosomes are both X then the child will develop in the womb into a girl (XX). The plan (gene) for the enzyme important in Lowe Syndrome is on the X chromosome. This is important, as it is the reason why only boys are affected by Lowe's syndrome.

Why are only boys affected?
Girls (XX) have two copies of the X chromosome and therefore two copies of the plan for the important enzyme. If one plan does not work they still have a 'back-up' copy. The back-up copy protects girls from developing Lowe's syndrome. Because boys are XY they only have one X chromosome and only one copy of the plan for the enzyme. They have no back-up copy. If their copy of the plan for the important enzyme has a misprint then the enzyme will not work. They will have no way of making any working enzyme. They will then develop Lowe's Syndrome.

Girls can still 'carry' Lowe's syndrome and pass it on to their children
Girls never develop Lowe's Syndrome but they can still carry the condition and pass it onto their children. Carriers have a misprinted gene for a condition but are not themselves affected. Female carriers of Lowe's dyndrome can in fact have mild signs of cataract. This can help identify who might be and might not be a carrier.

There is a 1 in 2 chance that a female carrier will pass the gene onto any son or daughter. It is chance which of her two X chromosomes will be passed on: whether it is the misprinted one or the normal X chromosome. This means that half her sons are likely to be affected and half unaffected. It also means that half her daughters will be carriers of the Lowe's syndrome gene and the other half unaffected and not carriers.

This is only a brief summary of the genetics of Lowe's Syndrome. There are exceptions to these general rules. This is why it is important that families with a child affected by Lowe's syndrome receive counselling from a specialist in genetics.

How does Lowe's syndrome cause Visual Impairment?
Children with Lowe's syndrome can have several problems with their eyes. These may include:

• Cataract
• Glaucoma
• Scarring of the cornea
• Nystagmus
• Squint
• Amblyopia

Few children have all these conditions. Nearly all will have cataracts and many will develop corneal scarring.

What is Cataract?
Cataract is when the normally clear lens of the eye becomes hazy. If the lens is not clear then not all the light can get into the eye and vision can be blurred. Cataract can be removed during an operation. Children usually need to wear spectacles afterwards. The operation is not always successful.

What is Glaucoma?
Eyes keep their shape by being pumped up with water. It is a bit like a football being pumped up and inflated with air. You can feel the 'pressure' in your own eyes by gently feeling them through your closed eyelids. The amount of pressure depends on the flow of water in and out of the eye. If the flow of water out of the eye becomes blocked the pressure goes up. High pressure in the eye can cause damage to the optic nerve. Glaucoma is when the optic nerve is damaged by high pressure in the eye. Sometimes drops will help reduce the pressure. Usually an operation is needed. This is called a trabeculectomy.

What is Corneal scarring?
The cornea is the clear, curved window at the front of the eye. It is important in focusing light sharply for clear vision. In children with Lowe Syndrome the cornea can become hazy. The haze is caused by scar tissue growing over the cornea. If the scar tissue covers the central part of the cornea vision will become blurred. An operation can cut away some of the scar tissue. This can help improve vision. It is not always successful however because it can cause new scar tissue to grow. Nobody knows why the scar tissue grows in the first place.

What is Nystagmus?
In some children the eyes are always moving 'to-and-fro' even though the object that they are looking at is still. This to-and-fro movement is called Nystagmus. Children do not know that they are doing it. Because the eye is shaking the vision is usually a bit blurred. This is like if a camera moves during a photograph. The photograph is also usually blurred. Nystagmus is common in children with visual impairment.

What is Squint?
A squint is when a child's eyes do not appear to be both looking in the same direction. A squint can sometimes be improved with spectacles or an operation. Despite this children rarely complain of double vision. This is because the child’s brain can 'ignore' vision from a squinting eye. This can lead to a 'lazy' eye or amblyopia.

What is Amblyopia?
If light from an object cannot be focused sharply on to the back of the eye then the child may develop a lazy eye. This is also known as Amblyopia. It is not actually the eye that has become lazy; it is the special vision parts of the brain. The brain can only learn to see as clearly as the picture given to it by the eyes. If the brain has not been given a sharp, clear picture by the eye it cannot learn to see clearly. Any of the eye conditions described above may cause blurred vision and Amblyopia. By treating these conditions the effects of amblyopia may be reduced. Wearing spectacles can also help to focus light sharply. Sometimes however even with correct spectacles and prompt treatment vision may still be blurred. This is because the brain has not developed the power to see clearly. This is called Amblyopia.

How does Lowe's syndrome affect the way a child sees?

Cataract and corneal scarring are the main causes of visual impairment in Lowe's syndrome. The cataracts are present from birth. Corneal scarring usually occurs later.

Most young children who are born with cataracts in both eyes feel their vision to be 'normal'. At first they assume that everyone else has vision the same as their own, as they have never known anything else but their own visual world. They do not realise that other people see things differently.

Some children will be only mildly affected and have near-normal vision. Others may have several problems with their eyes leading to poor vision.

How is Lowe's syndrome diagnosed?

When a baby is born doctors examine the eyes for signs of cataract. If cataract is noticed they can then ask an eye doctor to perform further tests.

Doctors will suspect Lowe's syndrome if the child is born with other typical features of the condition. The diagnosis can then be confirmed by a test for the activity of enzymes in the skin.

What can be done to treat cataracts?

Cataracts can be taken away by an operation. The cataracts are however only removed if they are causing blurred vision. If the cataracts are very dark and hazy they are almost certain to be causing poor vision. An operation is then needed to remove the cataracts soon after the child is born. This prevents the child growing up with blurred vision and lazy eyes (amblyopia).

If the cataracts are not too hazy it can be more difficult to decide if an operation is needed or not. It is sometimes difficult in younger children to tell how well they are seeing. Often it can be better to wait until the child is a little older before making the decision to do a cataract operation. When a child is older the eye doctor can be surer what the child's level of vision really is.

Once the hazy lens (cataract) has been removed it needs to be replaced by another lens. This can be a spectacle lens, a contact lens or a small plastic lens inside the eye (intraocular lens). Even after the cataract has been removed there may still be a lot of work to do. One eye may not see so well as the other. This may be because it is lazy (amblyopic). Patching of the good eye may need to be done to encourage the poorer eye to see. As an eye grows the strength of the new lens will need to be changed. The child will have to attend the hospital quite often for checks.

How can parents, family, friends and teachers make a difference?
Many things can be done to help children with Lowe's syndrome see better.

We use our vision to get around, learn new things and to meet other people and make friends.
Most children with Lowe Syndrome can give the impression that their vision is normal. It is important however to consider what your child’s particular problems with vision might be.

If your child has been prescribed spectacles, contact lenses or a Low Visual Aid (LVA) it is important that they are encouraged to wear and use them. This will help your child see more clearly and ensure the vision parts of the brain grow and develop correctly. Wearing a hat and tinted glasses can also help reduce problems from bright light. If your child has also been prescribed drops they should be used regularly as advised by the nurses and doctors at the eye clinic.

Problems at school may be due to some of the reading books being hard to see. This often means it takes longer and more effort to do the work. If the size of print is increased and letters and words spaced more widely most children will find schoolwork easier. Good bright lighting and crisp black print on a clean white background will also make things easier.

Some children may also benefit from using a computer software programme while reading. The programme only shows one word of a sentence at a time. It is in the middle of the computer screen. This reduces the need for fast eye movements. It can increase reading speed and reduce tiredness. The programme is called ACE READER. A demonstration can be downloaded from www.acereader.com. If you need any help with this please let us know.

It is also worth watching carefully to find out what the smallest toys are that a child can see and play with. Then try to only play with toys that are the same size or bigger. Placing one toy on a plain background will often help children see it more readily. Placing lots of toys of different size and colour close together on a patterned background can make them 'invisible' to some children.

Recognising facial expressions can often be difficult. It is worth trying to find out at what distance facial expressions can be seen and responded to. Then always try to talk and smile from within this distance. This helps a child to learn what facial expressions mean and to copy them.

Infants and young children need to learn about the world around them. Home visiting teachers, physiotherapists and occupational and speech therapists may all add to the child's care and education. It is important to continue the programmes that they recommend. If the child is involved in family activities vision can improve and new skills can develop.

Even if a child has very poor vision many useful and practical things can be done to improve the ability of the child to get around, interact with other children and learn.

Parents' Support Group