Morning Glory Syndrome

Overview

Morning glory syndrome is thought to arise from an abnormal closure of the embryonic fissure and is named after its resemblance to the flower of the same name.

This anomaly is characterised by a funnel-shaped excavation of the optic disc with straight, radial retinal vessels emerging from the disc. A white glial tuft is typically seen at the centre of the optic disc and the peripapillary region may show annular hyperpigmentation.

Approximately 50% of patients with morning glory syndrome may develop maculopathy or serous retinal detachment.

A variety of systemic and developmental conditions may be associated with morning glory syndrome. These can include midline craniofacial defects, neurocutaneous disorders, PHACE syndrome (which includes posterior fossa abnormalities, haemangioma and cardiovascular abnormalities amongst others).

Case Examples

  • Case 1

    A 24 year old Asian female with best corrected visual acuity of 6/120 (20/400) in the right eye. The left eye was unremarkable so this case will focus on the right eye only.

    Fundus photograph (right eye)

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    Fundus photograph (right eye)

    The right optic nerve shows significant excavation with extensive peripapillary ring shaped pigment. The emerging vessels follow a straight, radial course.

    Optomap and fundus autofluorescence images (right eye)

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    Optomap and fundus autofluorescence images (right eye)

    Autofluorescence imaging shows an extensive ring of hypo-autofluorescence surrounding the optic nerve corresponding to the peripapillary changes.

    Spectralis OCT line scan (right eye)

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    Spectralis OCT line scan (right eye)

    OCT imaging shows a wide area of chorioretinal atrophy adjacent to the optic disc. There are also spots of RPE hyperplasia within the atrophic areas.

    Cirrus RNFL analysis

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    Cirrus RNFL analysis

    OCT RNFL imaging in the right eye is unreliable due motion artefacts and segmentation errors.

  • Case 2

    A 7 year old Caucasian male with best corrected visual acuity of 6/7.5 (20/25) an unremarkable medical history.

    Fundus photograph (right and left eye)

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    Fundus photograph (right and left eye)

    Comparison of the two eyes shows a significantly increased size of the left optic nerve.

    Fundus photograph (1) red free (2) and fundus autofluorescence images (3)

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    Fundus photograph (1) red free (2) and fundus autofluorescence images (3)

    Closer examination shows a funnel shaped excavation of the left optic nerve with an annular ring of surrounding pigmentation. The emerging vasculature were increased in numbers with a straight radial course, characteristic of morning glory syndrome.

    Fundus autofluorescence shows hypoautofluorescence corresponding to the peripapillary changes.

    Spectralis OCT line scan (left optic disc)

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    Spectralis OCT line scan (left optic disc)

    OCT line scans shows deep posterior excavation of the optic nerve

  • Case 3

    A 35 year old Asian female with best corrected visual acuity in the right eye of 6/24 (20/80).

    Fundus photograph (right and left eye)

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    Fundus photograph (right and left eye)

    Funduscopy shows a large funnel-shaped excavation of the right disc, with surrounding pigment changes in a ring-shaped pattern. The blood vessels are increased in number, emerging from the excavated disc in a radial pattern rather than in a typical branching pattern. This is consistent with a morning glory disc.

    Stereoscopic image of the right optic nerve

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    Stereoscopic image of the right optic nerve

    Please use a stereoviewer or 15 prism dioptres base out to view the image.

    This image allows a better appreciation of the excavation of the optic nerve and a more magnified view of the blood vessels emerging radially.

    Spectralis OCT volume and line scan (right eye)

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    Spectralis OCT volume and line scan (right eye)

    OCT line scans through the optic nerve shows a funnel shaped cavity. The posterior vitreous remained adherent.

    Cirrus RNFL analysis

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    Cirrus RNFL analysis

    RNFL assessment is complicated by image truncation and segmentation errors.

    B-Scan ultrasound (right eye)

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    B-Scan ultrasound (right eye)

    B-scan ultrasound shows a posterior excavation in the region of the optic nerve.

Differential diagnosis

Megalopapilla

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Optic disc coloboma

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Congenital Optic disc pit

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Peripapillary Staphyloma

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References

Fei P, Zhang Q, Li J, et alClinical characteristics and treatment of 22 eyes of morning glory syndrome associated with persistent hyperplastic primary vitreousBritish Journal of Ophthalmology 2013;97:1262-1267.

Hu J. The clinical characteristics and imaging findings of morning glory syndrome. J Huazhong Univ Sci Technolog Med Sci. 2008 Aug;28(4):465-8.