Retinal pigment epithelium–photoreceptor layer alterations in a patient with Sturge–Weber syndrome with diffuse choroidal hemangioma

An Update on Multimodal Ophthalmological Imaging of Diffuse Choroidal Hemangioma in Sturge-Weber Syndrome

Sturge-Weber syndrome (SWS) is characterized by facial port-wine stains, leptomeningeal hemangiomas, and prominent ocular manifestations such as glaucoma and diffuse choroidal hemangiomas (DCHs). Imaging modalities are critical for diagnosing and longitudinally monitoring DCHs in SWS. Fundus photography is fundamental in assessing both eyes simultaneously, fluorescein angiography and indocyanine green angiography effectively map the retinal and choroidal circulation, and ultrasonography offers essential structural insights into the choroid and retina. NIR imaging reveals subtle retinal pigment changes, often overlooked in standard fundus examination. Enhanced depth imaging spectral domain optical coherence tomography (EDI-SDOCT) and swept-source OCT (SSOCT) improve the visualization of the choroidal-scleral boundary, essential for DCH characterization. The potential of OCT angiography (OCTA) is under exploration, particularly its role in predicting signs of disease progression or worsening, as well as potential new biomarkers such as the choroidal vascularity index (CVI). The present review aims to provide an update on multimodal imaging of DCHs in SWS.

The role of near-infrared reflectance imaging in retinal disease: A systematic review

Near-infrared reflectance (NIR) retinal imaging aids in a better visualization of structures at the level of outer retina, retinal pigment epithelium, and choroid. It has multiple advantages, including easy acquisition in association with structural spectral domain optical coherence tomography, more comfort for patients, and enhanced contrast and spatial resolution. It helps in the diagnosis of chorioretinal diseases that present with minimal funduscopic findings and can be used to follow up many chorioretinal conditions. We describe the chorioretinal NIR imaging appearance and the clinical role of NIR imaging in ocular inflammatory disease, vascular and acquired disease, degenerative disease, tumors, associated systemic condition, toxic and traumatic disease, optic nerve head conditions, and physiological findings.

Choroidal Vasculature Changes in Age-Related Macular Degeneration: From a Molecular to a Clinical Perspective

The contribution of choroidal vasculature to the pathogenesis of age-related macular degeneration (AMD) has been long debated. The present narrative review aims to discuss the primary molecular and choroidal structural changes occurring with aging and AMD with a brief overview of the principal multimodal imaging modalities and techniques that enable the optimal in vivo visualization of choroidal modifications. The molecular aspects that target the choroid in AMD mainly involve human leukocyte antigen (HLA) expression, complement dysregulation, leukocyte interaction at Bruch’s membrane, and mast cell infiltration of the choroid. A mechanistic link between high-risk genetic loci for AMD and mast cell recruitment has also been recently demonstrated. Recent advances in multimodal imaging allow more detailed visualization of choroidal structure, identifying alterations that may expand our comprehension of aging and AMD development.

OCT Imaging in Infants

Optical coherence tomography (OCT) is widely applied in diagnosis and management of retina diseases particularly macular diseases in adult retina practices. However, it has been under-utilized in pediatric retinal diseases especially in neonates and infants. Utilization of OCT in primary macular diseases in this age group is also uncommon and is less reported. Challenges involved in image acquisition and limitations with available devices technique can explain the limited research and accurate data availability in the literature in this field. Purpose of this review article is to summarize the use of OCT and its importance in various infantile retinal pathologies such as vascular diseases, tumors, retinal dystrophies, and optic nerve pathologies with primary focus on neonates and infants, along with infant choroid. In addition, we also discuss about future directions including OCT angiography for infants.

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.

Near-Infrared Reflectance Imaging in Retinal Diseases Affecting Young Patients

Near-infrared reflectance (NIR) is a noninvasive, contactless, and rapid in vivo imaging technique for visualizing subretinal alterations in the photoreceptor layer, retinal pigment epithelium, and choroid. The present report describes the application of this imaging method in retinal and choroidal pathologies affecting young patients where scarce cooperation, poor fixation, and intense glare sensation can result in a challenging clinical examination. A literature search of the MEDLINE database was performed using the terms "near-infrared reflectance" and "spectral-domain optical coherence tomography." Articles were selected if they described the diagnostic use of NIR in children or young adults. Of 700 publications, 42 manuscripts published between 2005 and 2020 were inherent to children or young adults and were considered in this narrative literature review. The first disease category is the phakomatoses where NIR is essential in visualizing choroidal alterations recognized as cardinal biomarkers in neurofibromatosis type 1, microvascular retinal alterations, and retinal astrocytic hamartomas. Another diagnostic application is the accurate visualization of crystals of various nature, including the glistening crystals that characterize Bietti crystalline dystrophy. Acute macular neuropathy and paracentral acute middle maculopathy represent a further disease category with young adulthood onset where NIR is not only diagnostic but also essential to monitor disease progression. A further interesting clinical application is to facilitate the detection of laser-induced maculopathy where funduscopic examination can be normal or subnormal. In conclusion, NIR imaging has a noninterchangeable role in diagnosing certain retinal diseases, especially in children and young adults where there is scarce collaboration and a lack of evident clinical findings. Moreover, this technique can reveal unique retinal and choroidal biomarkers highly specific to rare conditions.

Ocular Manifestations of the Sturge-Weber Syndrome

Sturge-Weber syndrome (SWS) or encephalotrigeminal angiomatosis is a non-inherited congenital disorder characterized by neurologic, skin, and ocular abnormalities. A somatic activating mutation (R183Q) in the GNAQ gene during early embryogenesis has been recently recognized as the etiology of vascular abnormalities in SWS. Approximately, half of the patients with SWS manifest ocular involvement including glaucoma as the most common ocular abnormality followed by choroidal hemangioma (CH). The underlying pathophysiology of glaucoma in SWS has not been completely understood yet. Early onset glaucoma comprising 60% of SWS glaucoma have lower success rates after medical and surgical treatments compared with primary congenital glaucoma. Primary angle surgery is associated with modest success in the early onset SWS glaucoma while the success rate significantly decreases in late onset glaucoma. Filtration surgery is associated with a higher risk of intraoperative and postoperative choroidal effusion and suprachoroidal hemorrhage. CH is reported in 40-50% of SWS patients. The goal of treatment in patients with CH is to induce involution of the hemangioma, with reduction of subretinal and intraretinal fluid and minimal damage to the neurosensory retina. The decision for treating diffuse CHs highly depends on the patient's visual acuity, the need for glaucoma surgery, the presence of subretinal fluid (SRF), its chronicity, and the potential for visual recovery.

Current concepts on diffuse choroidal hemangioma in Sturge Weber syndrome

Background: Diffuse choroidal hemangioma (DCH) is a benign vascular tumor that is characteristically found in the Sturge-Weber syndrome (SWS). Recent genetic discoveries demonstrate that DCH occurs sporadically from an activating mutation in GNAQ at codon R183. Mutations in GNAQ or GNA11 result in dysregulation of the mitogen-activated protein kinase, which influences gene transcription and results in cellular proliferation. DCH may not always be readily detected on routine ophthalmological examination, consequently diagnosis and multidisciplinary referral are often delayed.Purpose: A literature search was performed through April 2020 without a lower date limit. This review will summarize the pathogenesis, diagnosis and management of DCH.Discussion: Multimodal imaging facilitates early detection of the condition. In particular, enhanced depth imaging spectral domain optical coherence tomography enables non-invasive, high-resolution visualization of the choroid to even detect mild choroidal thickening. Management of symptomatic DCH is generally difficult and results in poor visual outcome, thus, treatment is generally unwarranted, unless the hemangioma complicated by serous retinal detachment. The main treatment method is radiation therapy with external beam radiation therapy, proton beam therapy, plaque brachytherapy, and gamma knife surgery where low doses of radiation entail fewer complications. One method of alternative management is with photodynamic therapy that, although less invasive with a lower rate of complications, is not always feasible or effective in cases with extensive exudative retinal detachment.Conclusions: Multimodal ophthalmological imaging facilitates diagnosis of DCH and lifelong surveillance is essential in patients.

Progressive retinal vessel malformation in a premature infant with Sturge-Weber syndrome: a case report and a literature review of ocular manifestations in Sturge-Weber syndrome

BACKGROUND

Sturge-Weber syndrome is a disorder marked by a distinctive facial capillary malformation, neurological abnormalities, and ocular abnormalities such as glaucoma and choroidal hemangioma.

CASE PRESENTATION

We report a case of progressively formed retinal vessel malformation in a premature male infant with Sturge-Weber syndrome and retinopathy of prematurity, after treatment with intravitreal anti-vascular endothelial growth factor (VEGF). The baby was born at 30 weeks gestation with a nevus flammeus involving his left eyelids and maxillary area. On postmenstrual age week 39, he received intravitreal anti-VEGF. Diffuse choroidal hemangioma became evident at 40 weeks, with the classic "tomato catsup fundus" appearance. These clinical findings characterized Sturge-weber syndrome. He presented with posterior retinal vessel tortuosity and vein-to-vein anastomoses at 44 weeks.

CONCLUSION

This is a rare case of documented progression of retinal vessel malformations in a patient with Sturge-Weber syndrome and retinopathy of prematurity.

Ocular manifestations in phakomatosis pigmentovascularis: Current concepts on pathogenesis, diagnosis, and management

Phakomatosis pigmentovascularis is a rare congenital multisystemic disease with variable manifestations where a vascular malformation of the skin is associated with a pigmentary nevus. Ocular involvement includes glaucoma, choroidal hemangioma, and pigmentary alterations that predispose to uveal melanoma. Diagnosis is made on clinical grounds, although recent advances in molecular genetics have better clarified the etiopathogenesis of the condition. The advent of improved imaging techniques such as enhanced depth imaging spectral domain optical coherence tomography has provided new insight into the ocular alterations, enabling better follow-up of patients. We review the ophthalmic manifestations of the disease with an update on etiopathogenesis and current management strategies.

Retinal manifestations of the neurocutaneous disorders

PURPOSE OF REVIEW

The neurocutaneous disorders are a genetically and phenotypically diverse group of congenital syndromes characterized by cutaneous, ocular, and central nervous system manifestations. This review provides an overview of the clinical features and retinal findings in selected neurocutaneous disorders.

RECENT FINDINGS

Advances in genetics and diagnostic retinal and neuroimaging allow for the recognition of retinal features of common neurocutaneous syndromes and for improved characterization of rarer entities based on previously underdiagnosed or unrecognized retinal findings.

SUMMARY

Better characterization of the neurocutaneous disorders allows for earlier recognition and the potential for expeditious vision-saving and life-saving treatment.

[Diffuse choroidal hemangioma as a manifestation of Sturge-Weber syndrome (a clinical case study)]

Encephalotrigeminal angiomatosis (Sturge-Weber syndrome) is a congenital sporadic disease characterized by angiomatosis of meningeal vessels, facial and eye capillaries. The article presents a clinical case of comorbidity between monolateral skin angioma, ipsilateral conjunctival and choroidal angiomas without intraocular pressure elevation. The case is unusual due to asynchronous manifestation of the clinical signs of Sturge-Weber syndrome. Facial angioma was diagnosed at birth, while conjunctival angioma appeared at the age of 45 - at the same time as monolateral hypermetropia, which may be the first symptom of diffuse choroidal angioma.

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.

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.

Pigment dispersion syndrome and pigmentary glaucoma: a review and update

INTRODUCTION

Pigment dispersion syndrome (PDS) is a condition where anomalous iridozonular contact leads to pigment dispersion throughout the anterior segment and the released pigment is abnormally deposited on various ocular structures.

CLINICAL PRESENTATION

The clinical presentation of PDS is defined by the presence of pigmented cells on the corneal endothelium, an increase of pigmentation of the trabecular meshwork, and mid-periphery transillumination defects of the iris. This syndrome, more common in myopes, is usually bilateral and can be associated with ocular hypertension or glaucoma. Secondary open-angle pigmentary glaucoma (PG) can develop due to reduction of the outflow of aqueous humour and consequent increase in intraocular pressure leading to glaucomatous optic neuropathy. Diagnosis of PG is commonly between 40 and 50 years of age, occurring more frequently in men. The advent of ultrasound biomicroscopy and anterior segment optical coherence tomography has contributed to enhancing our knowledge on the condition. Typical alterations of the anterior segment are the posterior insertion of the iris and iris concavity. Treatment of PG should be initiated early to hinder disease progression, glaucomatous damage, and vision loss. Management is based on medical therapy, laser iridotomy, selective laser trabeculoplasty, and filtration procedures.

CONCLUSIONS

The differential diagnosis of PDS with other disorders can be challenging and awareness of the condition together with meticulous ophthalmologic examination allows early diagnosis followed by appropriate management strategies. The present review is a comprehensive report on the clinical characteristics, pathogenesis, current management, and status quo of PDS and PG.