Ocular manifestations of Sturge-Weber syndrome: pathogenesis, diagnosis, and management

Undiagnosed Epileptic Case Since Childhood of Sturge-Weber Syndrome: First Case Report from Somalia

Sturge-Weber syndrome is a rare, sporadic, progressive neurocutaneous condition that presents with congenital hamartomatous malformations, epilepsy, and a variety of facial symptoms. We discussed a rare case of an eighteen-year-old female child who came to our neurology department with status epilepticus, mental impairment, and a port-wine in the lateral left side of her face. We diagnosed Sturge-Weber syndrome after a thorough neurological and radiological evaluation. The purpose of presenting this case is to illustrate both the characteristic presentation and the complications associated with managing Sturge-Weber syndrome.

Unilateral Glaucoma Without Facial Angioma in a Pediatric Patient: A Suspected Sturge-Weber Syndrome Variant

The authors report a case of a 5-month-old full-term infant with chronic conjunctival redness and elevated intraocular pressure in the right eye. Magnetic resonance imaging ruled out leptomeningeal angiomatosis. Despite lacking a typical port-wine mark, the diagnosis of Sturge-Weber syndrome was established based on specific observations in the right eye that involved unilateral vascular glaucoma. These findings included Haab striae, a larger axial length measurement, an increased number of episcleral vessels with blood in Schlemm canal, and a thicker choroid in the macular region. This is the first reported pediatric case with these specific ocular manifestations in the absence of facial angioma, highlighting the need for awareness among clinicians to avoid misdiagnosis and facilitate proper management. [J Pediatr Ophthalmol Strabismus. 2024;61(3):e19-e22.].

Current situation and influencing factors of disease uncertainty in parents of children with Sturge‒Weber syndrome: a retrospective study

BACKGROUND

Sturge Weber syndrome (SWS), can cause extensive capillary malformations on the face, head, trunk, and other parts of the body, and the eyes can also suffer optic nerve injury. Secondary glaucoma can cause blindness, which has the characteristics of a relatively hidden onset and unclear pathogenesis. The treatment of SWS secondary glaucoma has always been difficult, and due to the characteristics of the disease, there is uncertainty about the long-term efficacy and safety of various treatment methods for such patients.

METHODS

A total of 105 parents of children with SWS completed a self-designed general information questionnaire, a generalized anxiety questionnaire (GAD-7), a patient health questionnaire (PHQ-2), a stress perception scale (PSS-4), a simple coping scale (SCSQ) and a disease-uncertainty scale (PPUS).

RESULTS

The total uncertainty score of parents of children with SWS was 79.07 ± 13.24, and the average item score was 2.82 ± 0.47. Multiple linear regression analysis revealed that anxiety and simple coping were the main influencing factors of disease uncertainty among parents of children with SWS (P < 0.05).

CONCLUSIONS

Parents of children with SWS exhibit a high level of disease uncertainty. Medical staff should pay attention to the source of parents' disease uncertainty and provide targeted interventions, which are of great importance in reducing parents' disease uncertainty.

Enhanced Visibility of the Retinal Nerve Fiber Layer Defects by the Underlying Diffuse Choroidal Angioma in Sturge Weber Syndrome with Glaucoma

Aim

To describe a unique finding in a patient with Sturge-Weber syndrome (SWS) accompanied by glaucoma.

Background

Cases with SWS may have an associated choroidal angioma and glaucoma. The localized retinal nerve fiber layer (RNFL) defects induced by the associated glaucoma are better detected against the red background of the associated choroidal angioma.

Case description

A 15-year-old boy was presented with left-side SWS. The case was subjected to full clinical examination, intraocular pressure (IOP) measurements, color fundus photography, ultrasonography, visual field assessment, and optical coherence tomography (OCT) of the peripapillary RNFL and ganglion cell layer (GCC) analysis. The main clinical finding was the enhanced detection of defects of the RNFL against the red color of associated choroidal angioma in this glaucomatous eye.

Conclusion

There is enhanced clinical visibility of RNFL defects in presence of associated diffuse choroidal angioma in Sturge-Weber glaucoma.

Clinical significance

Easier clinical detection of RNFL defects in SWS glaucoma associated with diffuse choroidal angioma.

How to cite this article

Abdelrahman AM. Enhanced Visibility of the Retinal Nerve Fiber Layer Defects by the underlying Diffuse Choroidal Angioma in Sturge Weber Syndrome with Glaucoma. J Curr Glaucoma Pract 2023;17(1):52-54.

Phacomatosis pigmentovascularis with sturge-weber syndrome and congenital glaucoma: A rare case report

Phacomatosis pigmentovascularis (PPV) is a rare congenital disease characterized by the co-existence of cutaneous vascular malformation and pigmentary nevi with or without extracutaneous systemic involvement. Here, we present a 2-month old child diagnosed with phacomatosis cesioflammea type of PPV with Sturge-Weber syndrome and secondary congenital glaucoma of the left eye. She underwent combined trabeculotomy and trabeculectomy in the left eye for glaucoma and was started on anti-epileptics for seizure control following pediatric evaluation. Early screening and treatment initiation can prevent blindness and other systemic complications associated with PPV.

The Effectiveness of Propranolol in Managing Hemorrhagic Choroidal and Exudative Retinal Detachment following Ahmed Glaucoma Valve Implantation in Sturge-Weber Syndrome: Case Report and Literature Review

Sturge-Weber syndrome (SWS) is a congenital neurological disorder that is characterized by hamartomas involving the skin, brain, and eyes and marked by the presence of the facial port-wine stain, which consequently leads to various ocular complications. Among all ocular comorbidities, glaucoma is the most frequently witnessed in SWS patients with a prevalence of 30%–70%. If glaucoma is refractory to conventional medical management, surgical intervention can be considered. Common complications of glaucoma procedures in SWS are choroidal detachment and suprachoroidal hemorrhage. Moreover, we report a 6-year-old girl, known case of unilateral congenital glaucoma secondary to SWS. Despite being on maximal antiglaucoma drops and undergoing multiple surgical interventions, the patient had uncontrolled intraocular pressure of her right eye. A decision to proceed with Ahmed glaucoma valve implantation (AGVI) to the right eye was made. In the immediate postoperative period, the patient developed hemorrhagic choroidal detachment and exudative retinal detachment. A trial of oral propranolol (1.5–2 mg/kg/day) was then initiated for 4 months. After 30 days from oral propranolol course initiation, we started noticing a significant improvement of the hemorrhagic choroidal and exudative retinal detachment. Spontaneously, a marked reduction in subretinal fluid and suprachoroidal hemorrhage was also seen. Thus, the improvement was correlated with the propranolol therapy. Here, we report a significant improvement of the postoperative complications of AGVI in a patient with SWS, following 4 months of oral propranolol course (1.5–2 mg/kg/day). Further studies are needed to determine the dosage, duration, and optimal mechanism by which propranolol works in this situation.

Serous Retinal Detachment Resolution following Trabeculectomy in a Patient with Sturge-Weber Syndrome

Purpose:

To report a case of Sturge–Weber syndrome (SWS) complicated with uncontrolled glaucoma and serous retinal detachment (SRD) in the left eye that evolved with complete resolution after trabeculectomy.

Methods:

We report the case of a 10-year-old boy with SWS complicated with uncontrolled glaucoma and SRD in the left eye. In primary evaluation, he presented with a left-sided nevus flammeus affecting upper eyelid and best corrected visual acuity of 20/50 on the affected eye. Fundus examination revealed glaucomatous optic nerve neuropathy and diffuse choroidal hemangioma with overlying SRD, which were confirmed with spectral domain optical coherence tomography. Right eye was unremarkable.

Results:

The patient underwent trabeculectomy with mitomycin-C on the affected eye. Two weeks later, he presented with normalization of the intraocular pressure and substantial resolution of subretinal fluid (SRF), which improved to complete resolution of the SRD at 2 months of follow-up. In addition, there was an improvement of visual acuity from 20/50 to 20/40.

Conclusion:

This is the first report to describe a case of SWS associated with SRD and resolution of SRF after trabeculectomy.

Successful Reduction of Intraocular Pressure in a Patient with Glaucoma Secondary to Sturge-Weber Syndrome Using a Suprachoroidal Shunt

Aim

We present a case of successful reduction of intraocular pressure (IOP) in a patient with Sturge-Weber syndrome (SWS) and moderate open angle glaucoma using a suprachoroidal shunt.

Background

Patients with SWS glaucoma often have elevated episcleral venous pressure resulting in elevated IOP. This makes the conventional pathway for aqueous humor outflow a poor target for IOP reduction, yielding it difficult to treat. Medication and procedures that facilitate uveoscleral outflow have been more successful.

Case description

We present a case where a suprachoroidal shunt device (CyPass®) was used to reduce IOP in a patient with SWS. The IOP reduction has persisted for 12 months without complication or the requirement for topical prostaglandin analog use.

Conclusion

The uveoscleral pathway is a preferred target for IOP reduction in patients with elevated episcleral venous pressure. The CyPass device offers a promising ab interno minimally invasive glaucoma surgery (MIGS) approach to reduce IOP in cases where a pathologic pressure gradient exists in the trabecular meshwork.

Clinical significance

Glaucoma in patients with SWS has been historically difficult to treat. Previous surgical procedures that have been successful are more invasive and have required the creation of alternative drainage routes of aqueous humor. The CyPass device offers a promising less invasive option to reduce IOP in these patients.

How to cite this article

Junttila TL, Alberto N, Winkels M, et al. Successful Reduction of Intraocular Pressure in a Patient with Glaucoma Secondary to Sturge-Weber Syndrome Using a Suprachoroidal Shunt. J Curr Glaucoma Pract 2020;14(1):43-46.

Combined Viscodilation of Schlemm's Canal and Collector Channels and 360° Ab-Interno Trabeculotomy for Congenital Glaucoma Associated with Sturge-Weber Syndrome

Purpose

This case report demonstrates the potential role of the OMNI surgical system in the surgical management of congenital glaucoma.

Patients and Methods

The case was a 4-month-old full-term, otherwise healthy female infant with cutaneous hemangiomas of both upper lids, corneal edema in the right eye (RE) and IOP > 30 mmHg. Sturge-Weber syndrome (SWS) was diagnosed. The RE was surgically treated with ab-interno circumferential viscodilation and trabeculotomy.

Results

Through 10 months of follow-up, intraocular pressure was adequately controlled without the need for adjunctive medical therapy.

Conclusion

Given its advantages over other angle surgery techniques, this procedure's role in treating glaucomas of childhood warrants further evaluation.

Spherophakia and Ectopia Lentis in a Sturge-Weber Patient: A Case Report

Sturge-Weber syndrome (SWS) is a rare, sporadic neurocutaneous disorder, primarily characterized by port-wine stain (PWS) over the ophthalmic division of the trigeminal nerve (V1) territory (hallmark feature) and glaucoma (in 30-60% of cases). Other ocular manifestations include episcleral involvement of the PWS, choroidal vascular malformations, and iris heterochromia. Two previous reports also associated ectopia lentis concomitantly among these cases. However, here we report spherophakia as a novel ophthalmological finding in SWS. A 56-year-old female previously diagnosed with SWS presented to the outpatient clinic complaining of right-sided decreased visual acuity and pain after a fall. Phenotypically, the patient had a PWS around V1 territory and involvement of both eyelids. Previous relevant ocular history included retinal detachment without macular involvement, ocular hypertension, and phacodonesis. The slit-lamp examination showed anterior lens luxation and elevated intraocular pressure (IOP) of 40 mm Hg by tonometry. Prior to the surgical approach, the patient received hypotensive treatment for elevated IOP. After intracapsular lens extraction, measurements were consistent with spherophakia. Postoperatively, the patient underwent optical coherence tomography (OCT). There was cystic macular edema (CME) by OCT and a detached posterior hyaloid membrane. The patient fully recovered with topical treatment of bromfenac for CME. To the best of our knowledge, this is the first report of concomitant anterior lens luxation and spherophakia (novel association) in a SWS patient. Our findings supplement the differential ocular diagnoses in SWS and should be considered in the routine ocular exam, specifically of the anterior segment. CME occurred similar to otherwise healthy eyes. However, in this case, topical anti-inflammatory medications had a good response and were well-tolerated.

Vascular lesions of the head and neck: an update on classification and imaging review

Vascular lesions have a varied appearance and can commonly occur in the head and neck. A majority of these lesions are cutaneous and congenital; however, some may be acquired and malignant. The presentation and clinical history of patients presenting with head and neck lesions can be used to guide further imaging, which can provide important diagnostic and therapeutic considerations. This review discusses the revised International Society for the Study of Vascular Anomalies (ISSVA) classification system for vascular tumors and malformations, as well as explores the most common vascular anomalies including their clinical presentations and imaging findings.

Optical coherence tomography in pediatric patients: a clinical review

Optical coherence tomography has improved the ophthalmic clinical examination due to its ability to more accurately characterize pathology of the eye. Optical coherence tomography is now an integral imaging modality for many adult diseases of the retina and is a ubiquitous part of a retinal practice. However, although its use in adults is well recognized, the adoption of optical coherence tomography in pediatric patients may be undervalued as macular diseases in children are relatively uncommon. Recent technological advancements have made optical coherence tomography scans quicker and more precise, generating normative data and leading to more widespread use in children. In this review article, we discuss how pediatric optical coherence tomography data can be used to understand normal development, as well as diagnose and monitor retinal disease. In particular, we highlight clinical optical coherence tomography findings of several pediatric retinal conditions, including retinopathy of prematurity, congenital infections, retinal dystrophies, and phakomatoses such as neurofibromatosis.

Association of Somatic GNAQ Mutation With Capillary Malformations in a Case of Choroidal Hemangioma

Importance

Choroidal hemangiomas are defined by a thickened choroid owing to vessel overgrowth, which may increase the intraocular pressure and lead to glaucoma. Choroidal hemangioma and glaucoma often co-occur in patients with Sturge-Weber syndrome, a rare neurocutaneous disorder characterized by capillary malformations.

Objective

To determine whether the mutation found in most capillary malformations, GNAQ R183Q (c.548G>A), was present in the choroidal hemangioma of a patient with Sturge-Weber syndrome.

Design, Setting, and Participant

Using laser-capture microdissection, choroidal blood vessels were isolated from paraffin-embedded tissue sections, and genomic DNA was extracted for mutational analysis. Choroidal sections were analyzed in parallel. A patient with choroidal hemangioma and Sturge-Weber syndrome who had undergone enucleation was analyzed in this study at Boston Children's Hospital. Negative controls were choroidal tissue from an eye with retinoblastoma and unaffected lung tissue; brain tissue from a different patient with Sturge-Weber syndrome served as a positive control. Infantile hemangioma was analyzed as well. Data were analyzed in 2018.

Main Outcomes and Measures

The mutant allelic frequency of GNAQ R183 and GNAQ Q209L/H/P was determined by droplet digital polymerase chain reaction on isolated genomic DNA. The infantile hemangioma marker glucose transporter-1 was visualized by immunofluorescent staining of tissue sections.

Results

The GNAQ R183Q mutation was present in the patient's choroidal vessels (21.1%) at a frequency similar to that found in brain tissue from a different patient with Sturge-Weber syndrome (25.1%). In contrast, choroidal vessels from a case of retinoblastoma were negative for the mutation (0.5%), as was lung tissue (0.2%). The patient's choroidal tissue was negative for the 3 GNAQ mutations associated with congenital hemangioma and for the infantile hemangioma marker glucose transporter-1.

Conclusions and Relevance

The results suggest that a more accurate description for choroidal hemangioma in patients with Sturge-Weber syndrome is choroidal capillary malformation. This finding may explain why propranolol, used to treat infantile hemangiomas, has been largely ineffective in patients with choroidal hemangioma. Further studies are needed to corroborate this finding.

Bilateral diffuse choroidal hemangioma in Sturge Weber syndrome: A case report highlighting the role of multimodal imaging and a brief review of the literature

PURPOSE

To present a patient with bilateral choroidal hemangioma in Sturge-Weber syndrome (SWS) and highlight multimodal imaging techniques for early detection and management of ocular alterations.

METHODS

A 37-year-old woman with diagnosis of SWS presented to our unit. The patient had been treated with pulsed dye laser for bilateral nevus flammeus and had right leptomeningeal angiomatosis. She had glaucoma, but ultrasound biomicroscopy did not show anterior chamber or ciliary body alterations.

RESULTS

Enhanced depth imaging (EDI) spectral domain optical coherence tomography (SD-OCT) showed bilateral diffuse choroidal hemangiomas in both eyes with choroidal thickness above 1000 μm. B-scan ultrasound examination showed diffuse choroidal hemangioma in both eyes, with a choroidal thickness of 1.53 mm and 1.94 mm in the right and left eye (RE, LE), respectively. Peripapillary retinal nerve fiber evaluation showed thinning of the retinal nerve fiber layer in both eyes.

CONCLUSIONS

This report highlights multimodal imaging techniques for the critical assessment of patients with SWS, especially in rare cases with bilateral choroidal hemangioma of the choroid. Novel imaging modalities enable optimal management and follow-up of rare conditions, and our case adds further evidence to the existing literature.

The Bone Does Not Predict the Brain in Sturge-Weber Syndrome

BACKGROUND AND PURPOSE

It has been hypothesized that skull marrow signal alteration may represent an early disease manifestation of Sturge-Weber syndrome before development of its intracranial manifestations. We alternatively hypothesized that intraosseous changes are associated with the overlying port-wine stain rather than the intracranial stigmata of Sturge-Weber syndrome and hence are not a predictor of brain involvement.

MATERIALS AND METHODS

MR imaging of children presenting with port-wine stain and/or Sturge-Weber syndrome between 1998 and 2017 was evaluated by 2 pediatric neuroradiologists for marrow signal abnormality and pial angioma and other Sturge-Weber syndrome features: ocular hemangioma, atrophy, and white matter changes (advanced myelination). Groups were divided into port-wine stain-only (without intracranial Sturge-Weber syndrome features) and Sturge-Weber syndrome (the presence of cerebral pial angioma). The χ² test was performed to evaluate the association between port-wine stain and bone marrow changes and between osseous change and pial angioma.

RESULTS

We reviewed 139 cases: 40 with port-wine stain-only and 99 with Sturge-Weber syndrome with pial angioma. Fifteen of 99 cases of Sturge-Weber syndrome had no port-wine stain. In the port-wine stain-only cohort, 78% had ipsilateral bony changes and 17% had no intraosseous changes. In the Sturge-Weber syndrome cohort, 84/99 had associated port-wine stain, 91% (P < .01) had bony changes ipsilateral to the port-wine stain or had no bone changes in the absence of port-wine stain, and 77% (P = .27) had bony changes ipsilateral to a cerebral pial angioma. Eighty percent of patients with Sturge-Weber syndrome who lacked a port-wine stain also lacked marrow changes. Five patients with bilateral port-wine stain and bilateral marrow changes had only a unilateral pial angioma.

CONCLUSIONS

Intraosseous marrow changes are strongly associated with facial port-wine stain; no significant association was found between pial angioma and bone marrow changes.

Sturge-Weber syndrome-associated glaucoma and intraocular osseous metaplasia: a unique complicated case

A 30-year-old European man was admitted to our centre complaining about severe pain of the right eye (OD) and right part of the face, redness and no vision of the OD. He had an 18-year history of secondary to Sturge-Weber syndrome glaucoma, 6-month history of red eye and 1-week history of pain in OD. The best-corrected visual acuity was no light perception OD and 20/20 OS. Intraocular pressure was 36 mm Hg OD. Examination revealed endophthalmitis, Sturge-Weber syndrome-associated glaucoma and complicated cataract of OD.Unfortunately, no prescribed treatment helped this patient, so evisceration of OD was performed. During the evisceration, a subretinal 20 mm in width and 22 mm in length osseous tissue, partially vascularised, was removed surgically and was sent to the histological laboratory. Histopathologically, there were data of active inflammatory process, retinal detachment due to huge subretinal osseous metaplasia, gliosis and retinal pigment epithelial hyperplasia, and druses with ossification.

Trabeculectomy with Ologen implant versus mitomycin C in congenital glaucoma secondary to Sturge Weber Syndrome

AIM

To compare the efficacy and safety of collagen matrix implant [Ologen (OLO) implant] versus mitomycin C (MMC) with subscleral trabeculectomy (SST) for the surgical treatment of congenital glaucoma (CG) in Sturge-Weber Syndrome (SWS).

METHODS

A prospective comparative randomized study of 20 eyes of 16 patients with CG associated with SWS was divided into two groups. The first group (MMC Group) included 10 eyes that were subjected to SST with MMC. The second group (OLO Group) included 10 eyes that were subjected to trabeculectomy with a collagen matrix implant (OLO implant). Postoperative evaluation included intraocular pressure (IOP) level, bleb evaluation, complications, and the need for further medication or surgical intervention.

RESULTS

The mean preoperative IOP was 29±3.16 mm Hg in MMC and 29.8±3.08 mm Hg in OLO eyes. Mean 12-month percentage reduction in IOP was significant in both groups (57.9% and 56.3%). At the end of the 12 postoperative follow-up month, in the MMC Group, 80% of eyes achieved the complete success, 20% of eyes had qualified success with no failed surgery in comparison to OLO Group which 70% of eyes achieved the complete success, 20% of eyes had qualified success with 10% failed surgery. In terms of complications, the MMC Group had a higher rate of complications than the OLO Group in the form of thin polycystic bleb in 6 eyes (60%), blebitis in only one eye (10%) treated with topical antibiotics, shallow anterior chamber in two eyes (20%).

CONCLUSION

This study proves that the use of a collagen matrix implant yields equally effective results as MMC when combined with trabeculectomy for the treatment of CG in SWS. Furthermore, OLO implantation is safe and has low incidences of complications.

Combined cilioretinal artery and hemi-retinal vein occlusion in Sturge Weber syndrome: Expanding the clinical spectrum

A 9-year-old boy with the diagnosis of Sturge-Weber Syndrome, and port-wine stain involving the right side of the face, presented with acute visual loss of the right eye. Examination revealed a high intraocular pressure and a combined cilioretinal artery and inferior hemi-retinal vein occlusion in the right eye. Systemic work-up was negative. After controlling the intraocular pressure, gradual improvement of vision was noticed with simultaneous disappearance of signs of vascular occlusion.

Sturge Weber Syndrome: A Case Study

The aim of this case review was to touch upon the various clinical presentations and diagnostic features of Sturge-Weber syndrome (SWS) as seen in the dental/medical practice. Sturge-Weber syndrome is a rare congenital disorder that belongs to a group of disorders collectively known as the phakomatoses. The characteristic pathological elements of the disease include leptomeninges angioma extending out to cerebral cortex with angiomatous lesions on the same side and unilateral facial nevus that affects trigeminal nerve division. The classic oral lesions involve haemangiomatous gingival lesion limited on the same side of upper or lower jaw. An 18-year-old female patient reported to the Department of Oral Medicine and Radiology with oral manifestations of SWS. The evaluation of the patient, radiological findings as well as the management is discussed in this case report. It is important for the dental physician to be aware of the non-oral manifestations of SWS in order to identify and manage it appropriately. The challenge here is to see the oral manifestation as part of the syndrome and not as an isolated oral condition. Early diagnosis and appropriate treatment plan is imperative to prevent development of complications.

Pathophysiology, diagnosis, and management of glaucoma associated with Sturge-Weber syndrome

PURPOSE

Sturge-Weber syndrome (SWS), also known as encephalotrigeminal angiomatosis, is a condition which includes leptomeningeal hemangioma, facial angiomatosis or nevus flammeus, and ocular changes. SWS can lead to severe complications of anterior segment involving conjunctiva and eyelids, whereas posterior segment of the eye may also be affected by diffuse choroidal hemorrhages. This article was written with the objectives to determine the pathophysiology, diagnosis, and treatment of glaucoma associated with this rare and challenging disorder.

METHODS

A detailed literature search was conducted on PubMed, EMBASE, Cochrane Library, and Google Scholar using the key words. Forty-five articles matched our inclusion criteria that were included in this systematic review.

RESULTS

Glaucoma is the one of the commonest ocular manifestations of SWS. It is caused by anterior chamber malformations, increased pressure in the episcleral veins, and changes in ocular hemodynamics. Glaucoma associated with SWS is usually congenital but can develop adults as well. The treatment of glaucoma associated with SWS is quite challenging because of early-onset, severe visual field impairment at the time of diagnosis, and unresponsiveness to standard medical treatment. Several surgical procedures have been devised but the long-term control of the intraocular pressure and visual function remain unsatisfactory. Modifications in the filtration surgery techniques and use of newer anti-fibrotic agents have produced good control of intraocular pressure.

CONCLUSION

Management of glaucoma associated with SWS is multi-dimensional and needs both medical and surgical interventions for better control. The treatment should be devised on case to case basis depending upon the intraocular pressure, stage of the disease, and type of glaucoma.