Glaucoma and Klippel-Trenaunay-Weber syndrome

Bilateral Phacomatosis Pigmentovascularis in a Young Male with Developmental Glaucoma and Varicose Veins

Aim

To report a case of bilateral phacomatosis pigmentovascularis (PPV), in a young male,presenting with developmental glaucoma and high myopia along with systemic features of klippel trenanauy weber (KTW) syndrome.

Background

The co-existence of oculodermal melanocytosis (ODM)and port-wine stain was termed PPV by Ota. Port-wine stain presents as part of Sturge-Weber syndrome (SWS). KTW presents with varicose veins and tissue hypertrophy alongwith port-wine stain.

Case Description

A 22-year-old male presented with decreased vision owing to high myopia and advanced glaucoma. Incidental findings noted were pigmentary naevi along with facial port-wine stain, which collectively comprises PPV. Also noted were bilateral varicose veins which are usually seen in association with KTW. In view of advanced visual field damage and inability to control intraocular pressures (IOP) on topical medications, he underwent Glaucoma filtration surgery in both eyes. Intra-operatively care was taken to avoid sudden decompression by controlled anterior chamber paracentesis, and scleral flap closure with releasable sutures was done to prevent hypotony related complications in the immediate postoperative period. Such precautions lead to an uneventful postoperative recovery, and even at 3 years’ follow-up, the patient is maintaining IOP in early teens along with a stable visual acuity and visual fields.

Conclusion

This case highlights the overlapping features of congenital conditions like oculodermal melanocystosis (ODM), SWS, KTW; presenting in a young male. Systemic features reported less frequently with PPV, included palatal pigmentation and palatal vascular malformations.

Clinical Significance

This case re-emphasizes a common origin of these entities, PPV and KTW, from the neural crest cells. Early recognition of the systemic features and timely surgical intervention under appropriate precautions, can be vision salvaging in such cases of developmental glaucoma.

How to cite this article: Singh K, Dangda S, Mutreja A, Bhattacharyya M, Jaisingh K. Bilateral Phacomatosis Pigmentovascularis in a Young Male with Developmental Glaucoma and Varicose Veins. J Curr Glaucoma Pract 2018;12(2):94-98.

Ophthalmic Alterations in the Sturge-Weber Syndrome, Klippel-Trenaunay Syndrome, and the Phakomatosis Pigmentovascularis: An Independent Group of Conditions?

The phakomatoses have been traditionally defined as a group of hereditary diseases with variable expressivity characterized by multisystem tumors with possible malignant transformation. The Sturge-Weber syndrome, Klippel-Trenaunay syndrome, and the phakomatosis pigmentovascularis have the facial port-wine stain in common. Numerous pathophysiogenetic mechanisms have been suggested such as venous dysplasia of the emissary veins in the intracranial circulation, neural crest alterations leading to alterations of autonomic perivascular nerves, mutation of the GNAO gene in the Sturge-Weber syndrome, PIK3CA mutation in malformative/overgrowth syndromes such as the Klippel-Trenaunay syndrome, and the twin-spotting phenomenon in phakomatosis pigmentovascularis. Other features linked to the port-wine stain and typical to all of the three conditions are glaucoma and choroidal alterations. Glaucoma can be due to malformations of the anterior chamber or high episcleral venous pressure and in phakomatosis pigmentovascularis it can also be associated with angle hyperpigmentation. The choroid can be thickened in all diseases. Furthermore, choroidal melanocytosis in the phakomatosis pigmentovascularis can lead to malignant transformation. Although the multiple pathophysiological mechanisms still require clarification, similarities in ophthalmic manifestations make it reasonable to classify these diseases in an independent group.

Glaucoma in phakomatosis pigmentovascularis

BACKGROUND

Sturge-Weber syndrome, Klippel-Trenaunay-Weber syndrome, and oculodermal melanocytosis are neural crest disorders in which glaucoma is known to occur. Phakomatosis pigmentovascularis is a neural crest disorder that is found almost exclusively in Asians and has not been described previously in the ophthalmic literature.

METHODS

The authors describe nine patients with combined oculodermal vascular malformations (five pigmentovascularis, two Klippel-Trenaunay-Weber, two Sturge-Weber) and oculodermal melanocytosis.

RESULTS

Ocular melanocytosis was present bilaterally in seven patients and unilaterally in two. Of the 16 hyperpigmented eyes, 13 also had episcleral vascular malformations (EVM). Congenital glaucoma developed in all 10 eyes that had total melanocytosis and EVM. Ocular hypertension developed in one eye with diffuse melanocytosis but partial EVM in childhood. Glaucoma did not develop in one eye with extensive EVM but partial melanocytosis or in the four eyes with ocular melanocytosis but not EVM.

CONCLUSION

When oculodermal melanocytosis and nevus flammeus (phakomatosis pigmentovascularis) occur together, with each extensively involving the globe, there is a strong predisposition for congenital glaucoma. When one or both are present with only partial involvement, elevated intraocular pressure may develop later in life, and patients should be followed-up at regular intervals for the development of glaucoma. The vascular malformations appear to play a more important role in the predisposition to glaucoma than does the oculodermal melanocytosis.

Glaucoma in oculodermal melanocytosis

Oculodermal melanocytosis (ODM) is a developmental disorder of the embryonic neural crest involving virtually all of the structures of the eye derived from this tissue. The authors examined 194 previously unreported Thai patients with ODM. Elevated intraocular pressures (IOPs) developed in the ipsilateral eye of 15 patients at initial examination and in 5 others during follow-up, for a total of 10.3% of the patients. Three patients had congenital or late congenital glaucoma, 14 had ocular hypertension or open-angle glaucoma, and 3 had acute angle-closure glaucoma. Five of the patients with open angles had acute pressure rises accompanied by anterior uveitis. Melanocytic hyperpigmentation of the anterior chamber angle was extensive in all patients except those with acute angle-closure glaucoma. There was no consistent correlation between the extent or density of angle pigmentation and the development of elevated IOP. A larger cup-to-disc ratio in the involved eye, presumably congenital, was present in an additional 19 patients. Glaucoma is common in eyes with ODM and may develop at any age. Patients with ODM and initially normal IOP should be examined at regular intervals. Patients with open angles and acutely elevated IOP should be examined carefully for signs of anterior uveitis and treated medically.