SciELO - Scientific Electronic Library Online

 
vol.74 issue1Anatomic and functional outcome of eyes with massive submacular hemorrhage secondary to retinal macroaneurysm submitted to vitrectomyBranch retinal artery occlusion in Susac's syndrome author indexsubject indexarticles search
Home Pagealphabetic serial listing  

Services on Demand

Journal

Article

Indicators

Related links

Share


Revista Brasileira de Oftalmologia

Print version ISSN 0034-7280

Rev. bras.oftalmol. vol.74 no.1 Rio de Janeiro Jan./Feb. 2015

http://dx.doi.org/10.5935/0034-7280.20150008 

Case Report

Bilateral Sturge-Weber Syndrome and glaucoma controlled with Ahmed valve implant

Síndrome de Sturge-Weber e glaucoma bilateral controlado com implante de válvula de Ahmed

Marcelo Jarczun Kac1 

Karina Nagao2 

Sansão Isaac Kac3 

Marcelo Palis Ventura2 

1Universidade do Estado do Rio de Janeiro (RJ), Hospital Universitário Pedro Ernesto – Rio de Janeiro (RJ), Hospital Universitário Antônio Pedro – Niterói (RJ), Universidade Federal Fluminense – Niterói (RJ), Brazil

2Universidade Federal Fluminense – Niterói (RJ), Hospital Universitário Antônio Pedro – Niterói (RJ), Brazil

3Hospital Federal dos Servidores do Estado – Rio de Janeiro (RJ), Brazil

ABSTRACT

Sturge-Weber Syndrome is a rare neuro-oculocutaneous disorder. The authors describe the case of a 13 years old boy, presented with bilateral Sturge-Weber Syndrome and glaucoma. Surgical treatment with Ahmed valve implantation in both eyes was carried out achieving lower levels of intraocular pressure.

Key words: Glaucoma; Glaucoma drainage implants; Sturge-Weber Syndrome; Port-wine stain; Case reports

RESUMO

A síndrome de Sturge-Weber trata-se de uma doença neuro-óculocutânea rara. Os autores relatam o caso de um paciente do sexo masculino, de 13 anos de idade, que se apresentou com Síndrome de Sturge-Weber bilateral e glaucoma. Foi realizado o tratamento cirúrgico com implante de válvula de Ahmed em ambos os olhos e alcançado a redução da pressão intraocular bilateral.

Palavras-Chave: Glaucoma; Implantes para drenagem de glaucoma; Síndrome de Sturge-Weber; Mancha vinho do porto; Relatos de casos

Sturge-Weber Syndrome (SWS) is one of the systemic hamartomatoses (phakomatoses). It is a rare neuro-oculocutaneous disorder(1). Clinically, the neurological component manifests as epilepsy, mental retardation, and hemiplegia; the ocular component manifests as glaucoma and vascular malformations of the conjunctiva, episclera, choroid, and retina ; and the dermal as the familiar nevus flameus, or port-wine stain(2).

Glaucoma is more common in SWS than in any other systemic hamartosis, but its precise incidence is unknown(3). It occurs as often as in 50% of the cases when the port-wine stain involves the maxilar and ophthalmic divisions of the trigeminal nerve(4). The results of therapy for glaucoma associated with the Sturge-Weber syndrome are often disappointing(5).

In this case report we describe a 13 year-old boy presented with bilateral SWS and glaucoma controlled after surgery with Ahmed implants.

CASE REPORT

A 13 year-old boy was refereed from the neurological department in 2010 for evaluation of Sturge-Weber Syndrome and low visual acuity. By this time he was already in use of Travoprost, Dorzolamide and Timolol Maleate ophthalmic solutions; and carbamazepine, clobazam and lamotrigine for the neurologic symptoms. He carried a bilateral facial angioma since birth (figure 1). Visual acuity was 1.0 in the right eye (OR) (refraction: -0.25 -0.50 X 15º) and 0.2 in the left eye (Os) (refraction: -3.50 -0.75 X 130°). Intraocular pressure was 22/ 24mmHg in OR and OS respectively at 09:30am. At gonioscopy, blood was observed in Schlemm’s canal in OS. Scleral spur was seen in both eyes. Central corneal thickness was 612/600|im in OR and OS respectively. Fundoscopy revealed a cup to disk ratio of 0.6 X 0.6 in OR and 0.9 X 0.9 in OS (figure 2A).

Figure 1 Bilateral facial angioma presents in patient with Sturge- Weber Syndrome 

Figure 2 A – Cup to disk ratio of 0.6 X 0.6 in right eye and 0.9 X 0.9 in left eye in 2010; B – Cup to disk ratio in right and left eyes in 2012 without glaucomatous damage progression 

Patient was submitted to surgical Ahmed valve implantation in both eyes. One month separated both procedures. Two years after the surgery, the patient presents intraocular pressure of 15mmHg at 10:00am in both eyes under fixed combination of dorzolamide and timolol maleate bid. Gonioscopy examination did not reveal blood in Schlemm’s canal any longer. Visual acuity was still 1.0 in OR but dropped to count fingers at 1 meter in OS. There was no apparent progression between 2010 and 2012 of the cup to disk ratio as observed in retinographies (figure 2B). The Ahmed valves were implanted over the temporal superior sclera in a one stage procedure without any further complications (figure 3).

Figure 3 Biomicroscopy pictures showing Ahmed valve positioned over the temporal superior sclera in both eyes 

DISCUSSION

Glaucoma associated with SWS is a rare and usually unilateral condition(4). Here we describe a case of a bilateral disease with asymmetric optic disk damage.

The glaucoma’s pathophysiology in SWS has been investigated for many years. Two mechanisms for glaucoma are theorized. In cases with buphthalmos and congenital glaucoma, the chamber angle is often anomalous, as in other types of congenital glaucoma. In later onset juvenile cases, the chamber angle more often appears normal. A premature aging of the trabecular meshwork and the Schlemm’s canal complex, as shown by Cibis et al. histopathologically, is a primary cause of juvenile glaucoma(6). It is suggested that both mechanisms relate to the abnormal hemodynamics of episclera and chamber angle, due to persistence of Streeter’s primordial vascular plexus(6). More recent studies support the hypothesis that elevated episcleral venous pressure plays an important role in eyes with SWS glaucoma(7). Frequently, patients with SWS and glaucoma have choroidal hemangiomas and/or episcleral or conjunctival hemangiomas(4), however this patient did not present any of these.

Clinical therapy for glaucoma in SWS if often ineffective and most patients require glaucoma surgery for a better intraocular pressure control. Trabeculectomy is associated with a high number of post-operative complications as choroidal effusion(8). Other options for treatment described are goniotomy and trabeculotomy in early onset cases(4). Van Emelen et al. had good results with cryocoagulation of the ciliary body combined with topical medication(9). Some authors described less complications with glaucoma implants(1,10,11), which is why we have chosen to perform this type of procedure primarily.

Institution where the work was performed: Department of Ophthalmology, Universidade Federal Fluminense, Hospital Universitário Antônio Pedro – Niterói (RJ), Brazil

REFERENCES

1 Awad AH, Mullaney PB, Al-Mesfer S, Zwaan JT. Glaucoma in Sturge-Weber syndrome. J AAPOS. 1999;3(1):40-5. [ Links ]

2 Sullivan TJ, Clarke MP, Morin JD. The ocular manifestations of the Sturge-Weber syndrome. J Pediatr Ophthalmol Strabismus. 1992;29(6):349-56. [ Links ]

3 Nelson LB, Calhoun JH, Harley RD. Pediatric ophthalmology. 3rd ed. Philadelphia: WB Saunders; 1991. p. 437-40. [ Links ]

4 Allingham RR, Damji KF, Freedman S, Moroi SE, Rhee DJ. Shield's textbook of glaucoma. 5th ed. Philadelphia: Lippincott Williams & Wilkins; 2005. [ Links ]

5 Ozieb3o-Kupczyk M, Urban B, Mrugacz M, Bakunowicz-Lazarczyk A. [The evaluation of the efficacy of treatment in glaucoma associated with Sturge-Weber syndrome]. Klin Oczna. 2007;109(1-3):46-8. Polish. [ Links ]

6 Cibis GW, Tripathi RC, Tripathi BJ. Glaucoma in Sturge-Weber syn-drome. Ophthalmology. 1984;91(9):1061-71. [ Links ]

7 Shiau T, Armogan N, Yan DB, Thomson HG, Levin AV The role of episcleral venous pressure in glaucoma associated with Sturge-We-ber syndrome. J AAPOS. 2012;16(1):61-4. [ Links ]

8 Bellows AR, Chylack LT Jr, Epstein DL, Hutchinson BT. Choroidal effusion during glaucoma surgery in patients with prominent episcleral vessels. Arch Ophthalmol. 1979;97(3):493-7. [ Links ]

9 van Emelen C, Goethals M, Dralands L, Casteels I. Treatment of glaucoma in children with Sturge-Weber syndrome. J Pediatr Ophthalmol Strabismus. 2000;37(1):29-34. [ Links ]

10 Budenz DL, Sakamoto D, Eliezer R, Varma R, Heuer DK. Two-staged Baerveldt glaucoma implant for childhood glaucoma associated with Sturge-Weber syndrome. Ophthalmology. 2000;107(11):2105-10. [ Links ]

11 Figueiredo LR, Silva Filho FJ; Rehder JR. [Sturge-Weber syndrome and its ocular effects: a review]. Rev Bras Oftalmol. 2011;70(3):194-9. Portuguese. [ Links ]

Received: February 10, 2013; Accepted: September 19, 2013

Corresponding author: Marcelo Jarczun Kac, Av. Nossa Sra. de Copacabana, nº 680 – sl. 1203, ZIP Code: 22050-001 – Rio de Janeiro (RJ), Brazil, Fax: 55 (21) 2236-2799. E-mail: marcelojkac@gmail.com

The authors declare no conflicts of interest

Creative Commons License This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.