Solitary idiopathic choroiditis: findings on enhanced depth imaging optical coherence tomography in 10 cases

GROWTH OF A FOCAL SCLERAL NODULE

PURPOSE

To report a case of a focal scleral nodule (FSN) that demonstrated growth over three years.

METHODS

Case report.

RESULTS

An asymptomatic emmetropic 15-year-old female patient was referred with an incidental finding of a left fundus lesion on routine examination. On examination, there was an isolated 1.9-mm (vertical) × 1.4-mm (horizontal) diameter-raised, circular, pale, yellow-white lesion with an orange halo located along the inferotemporal vascular arcade. Enhanced-depth imaging optical coherence tomography (EDI-OCT) demonstrated a focal protrusion of the sclera with thinning of the overlying choroid, consistent with focal scleral nodule (FSN). On EDI-OCT, the horizontal basal diameter measured 3138 μm, and its height was 528 μm. Three years later, the lesion had increased in size to 2.7-mm (vertical) × 2.1-mm (horizontal) diameter on color fundus photography and a horizontal basal diameter of 3991 μm and height of 647 μm on EDI-OCT. The patient remained systemically well without visual complaints.

CONCLUSION

FSN can increase in size over time, suggesting that scleral remodeling within and around the lesion can occur. Longitudinal observation of FSN can help to inform its clinical course and shed insight into its pathogenesis.

SOLITARY PUNCTATE CHORIORETINITIS: A Unique Subtype of Punctate Inner Choroidopathy

PURPOSE

To describe a case series of a special subtype of punctate inner choroidopathy with solitary lesions in the macular area and named solitary punctate chorioretinitis.

METHODS

This retrospective observational study clinically evaluated 12 eyes from 12 patients diagnosed as punctate inner choroidopathy with solitary lesions. Demographic data and multimodal imaging features were analyzed for the included patients.

RESULTS

All the included patients were Chinese and of Han ethnicity. The median age of the included patients was 29.5 years (range: 25-40 years). Most patients (11/12, 91.67%) were myopic, with median refraction errors of -4.4 diopters (D) (range: -8.5 to 0 D). Solitary chorioretinitis lesions were yellow‒white and appeared hyperfluorescent during the entire phase of fundus fluorescein angiography without leakage (9/12, 75%) and hypofluorescent on indocyanine green angiography (11/11, 100%). On spectral domain optical coherence tomography, active inflammatory lesions appeared as isolated, heterogeneous, moderately reflective material at the outer retina (10/12, 83.33%) in the fovea or parafoveal region with disruption of the outer retinal layers. When the inflammatory lesions regressed, the moderately reflective materials in the outer retina were absorbed or regressed with outer retinal tissue loss. Additional sequelae of lesion regression included focal choroidal excavation and intraretinal cystoid space. Secondary choroidal neovascularization was noticed in 2 eyes (2/12, 16.67%).

CONCLUSION

Solitary punctate chorioretinitis is a rare and unique subtype of punctate inner choroidopathy. Solitary punctate chorioretinitis may also be an unrecognized etiology of some forms of focal choroidal excavation and idiopathic choroidal neovascularization.

PIGMENTATION IN FOCAL SCLERAL NODULE

PURPOSE

To report a case of pigmentation in focal scleral nodule (FSN).

METHODS

This is a single case report.

RESULT

An asymptomatic 61-year-old woman was referred with small, partially pigmented raised lesion located at the superior margin of the optic nerve head. The lesion's clinical and multimodal imaging features were consistent for FSN including a dome-shaped elevation confined to the sclera with overlying choroidal thinning. However, the pigmentation within our lesion is a novel finding in FSN that has not been described before.

CONCLUSION

To our knowledge, we report the first case of pigmentation in FSN. It is likely that our case was a typical FSN that then became pigmented, with melanosomes involving the flanges of the lesion where thin choroid remains. The understanding that FSN can be partially pigmented may eventually help unravel the origins of this poorly understood lesion.

Imaging characteristics of idiopathic scleroma: a retrospective case series and review of the literature

BACKGROUND

Idiopathic scleroma (previously coined solitary idiopathic choroiditis or focal scleral nodule) is an innocuous lesion affecting the sclera with intraocular manifestations. It is often the basis of many misdiagnoses such as amelanotic choroidal melanoma, osteoma or metastatic lesions. Patients are often asymptomatic and the course is benign. With increasing use of community based imaging, more of such cases are being identified. This paper is a retrospective case series investigating the multi-modal imaging findings of idiopathic scleroma.

METHODS

A retrospective analysis of prospectively collected data were analysed. Over the course of January 2008-January 2022, 44 patients diagnosed with idiopathic scleroma and imaged with wide-field colour fundus photography, fundus autofluorescence, ocular coherence tomography (OCT) and B-scan ultrasonography. Due to a poor image, only 43 images were included for OCT review. We also reviewed our patient's demographics, symptoms and baseline ophthalmic characteristics upon presentation.

RESULTS

The mean age was 52 years (range 32-79) and there was no predilection towards gender. All lesions were post equatorial with the most common location being inferotemporal (n = 16, 36%); 32 lesions (73%) were yellow on fundus photography. 82% (n = 36/44) of lesions exhibited hyperautoflourescence and 43 lesions (98%) showed hyperechogenicity on B-scan ultrasonography. 100% of lesions originated from the sclera with no lesions showing active inflammation. 20 (47%) lesions had associated blood vessels overlying them on OCT.

DISCUSSION

Idiopathic scleroma is a yellow, hyperautofluorescent, hyperechogeneic scleral lesion that has no signs of active inflammation. These characteristics help define them from other more sinister cause of amelanotic fundal lesions.

Expanded spectrum of focal scleral nodule: focal scleral nodules can be bifocal

BACKGROUND

To assess multimodal imaging findings of focal scleral nodule (FSN) to evaluate its origin and natural course.

METHODS

This was a retrospective observational case series and included 14 patients with FSN who underwent multimodal imaging. Clinical information was gathered from patients' medical records. Primary outcome measures were standardized grading of imaging features.

RESULTS

The mean follow-up duration was 68.8 ± 43.6 months (range, 6-139 months). Most lesions were solitary (92.6%), but one patient had two adjacent lesions (7.1%). Optical coherence tomography revealed that all lesions were confined to the sclera. Lesions showed mostly outer retinal abnormality, with external limiting membrane thinning or absence in 41.6% of lesions and ellipsoid layer absence in 84.6% of lesions. Most lesions showed an absence (69.2%) or thinning (23.1%) of the choroid above the lesion, and the mean choroidal thickness above the lesion for choroids with measurable thickness was 36 ± 75 μm (median, 0; range, 0-265 μm). Of 13 lesions with available follow-up data, only three lesions showed minimal growth over time.

CONCLUSIONS

This study demonstrates for the first time that bifocal lesions of FSN in the same eye are possible and reaffirms the relative stability of this entity.

Ocular Tumor in a Woman With Breast and Kidney Carcinomas

A 54-year-old woman with a history of lobular breast carcinoma in situ as well as chromophobe kidney cell carcinoma was referred for evaluation of an asymptomatic, amelanotic choroidal mass in her left eye. Examination revealed a hyperautofluorescent amelanotic lesion primarily in the sclera that pushed and thinned the overlying choroid. What would you do next?

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.

Clinical Features and Multimodal Imaging Findings of Focal Scleral Nodule: Potential Association between Lesion Characteristics and Age

OBJECTIVE

To describe the clinical course and anatomic features of focal scleral nodules (FSNs) based on their clinical characteristics and multimodal imaging findings and analyze their potential associations with the patient's age.

DESIGN

Single-center, retrospective, observational case series.

SUBJECTS

Twenty-three lesions of 23 patients with FSN.

METHODS

Clinical characteristics were analyzed, and multimodal imaging was performed, including color fundus photography, OCT, fundus autofluorescence imaging, near-infrared imaging, B-scan ultrasonography, fluorescein and indocyanine green angiography, and OCT angiography of FSNs.

MAIN OUTCOME MEASURES

Qualitative features, including the slope of anterior curvature (curvature of the dome shape is less than nodular curvature, which is less than volcanic curvature; i.e., volcanic curvature has the steepest slope), retinal pigment epithelium (RPE) status, and fluid compartments, were analyzed. Quantitative measurements, including maximum linear basal diameter, maximum horizontal length at the choroidoscleral border, maximum vertical length (V_max) from the choroidoscleral border, and choroidal thickness, were analyzed.

RESULTS

The mean age at presentation was 44 ± 17 years (range, 4-68 years), and the mean follow-up duration was 32.2 ± 29.5 months. On OCT, all lesions were confined to the sclera. Patients with volcanic or nodular anterior curvature were younger than those with the dome-shaped phenotype (35 ± 19 years vs. 52 ± 9 years, respectively; Mann-Whitney U test; P = 0.015). The Spearman rank correlation analysis displayed a significant correlation between age at diagnosis and V_max (r = -0.466; P = 0.025). The Wilcoxon matched paired t test for the patients demonstrated a significant decrease in V_max at the final follow-up visit (initial, 555 ± 228 μm vs. final, 517 ± 202 μm, respectively; P = 0.028). We observed subretinal fluid, intraretinal fluid, pigment epithelial detachment, and severe outer retinal atrophy in a relatively older population with sustained nodular or volcanic anterior curvature (age, 52 ± 7 years; range, 43-60 years). One lesion diagnosed in a patient aged 4 years demonstrated spontaneous regression.

CONCLUSIONS

Young patients tended to have protruded lesions (high V_max) with nodular or volcanic anterior curvature. Older patients manifested the dome-shaped phenotype, and those with sustained nodular or volcanic curvature tended to develop fluid compartments or atrophic changes of the overlying RPE and retina because of possible chronic mechanical compression. Thus, there could be a significant association between FSN phenotype and age.

Choroidal granulomas due to Bartonella henselae infection: A case series

PURPOSE

To report a case series of 3 patients with choroidal granulomas due to Bartonella henselae infection in order to raise awareness about this etiology in the differential diagnosis of choroidal granulomas.

METHODS, PATIENTS

A retrospective case series of patients with choroidal granulomas due to Bartonella henselae infection who consulted between 2018 and 2020. Data were collected from the medical records (demographics, visual acuity (VA), laboratory tests, treatment, imaging).

RESULTS

Patients were a 48-year old man, a 14-year old girl and a 31-year old man. They all had a choroidal granuloma seen on optical coherence tomography (OCT) and angiography. The laboratory work-up revealed a positive serology for Bartonella henselae in all patients.

CONCLUSION

On multimodal imaging choroidal granulomas in B Henselae appeared as single or multiple, uni or bilateral round yellowish lesions. Fluorescein and indocyanine green angiography of the granuloma showed respectively a late staining and a hypofluorescence. On EDI-OCT choroidal granuloma appeared as a round hyporeflective lesion in the choroid with a retinal elevation. The exclusion of other diagnosis, the natural course and the serology must lead the ophthalmologist to evoke the diagnosis.

Multimodal Imaging Features of Focal Scleral Nodule

This article describes a 63-year-old woman with a yellow-white mass in the inferior juxtapapillary region discovered on routine ocular examination. She was diagnosed as solitary idiopathic choroiditis (SIC) after an extensive ocular examination. SIC is a rare condition of unknown aetiology that can sometimes be mistaken as inflammatory processes or intraocular tumors. Solitary idiopathic choroiditis is suspected clinically and the diagnosis is established with multimodal imaging, so CIS has been renamed focal scleral nodule because of the scleral location.

A Case Series of "Solitary Idiopathic Choroiditis" and Proposal of a Nomenclature Change to "Idiopathic Scleroma"

Objective

To define the characteristics of solitary idiopathic choroiditis (SIC) in a consecutive series of patients and propose a nomenclature change to idiopathic scleroma.

Materials and Methods

Electronic patient records were retrospectively interrogated to identify all patients diagnosed with SIC between 2002 and 2019 in a tertiary referral ophthalmic hospital in the United Kingdom.

Results

Thirty-four eyes of 34 patients were found to have SIC. The mean age at diagnosis was 48 years (range 24-78) and 23 patients (68%) were female. All lesions were located posterior to the equator, most frequently in the inferotemporal quadrant (13 eyes, 38%). The lesions had a mean largest basal diameter of 1.2 ± 0.4 disc diameters (range 0.5-2) and their distance to the optic disc had a mean of 1.2 ± 0.9 disc diameters (range 0-3.3). All lesions were intrascleral on enhanced depth imaging optical coherence tomography, demonstrating a hypo-reflective zone within the sclera, with an underlying hyper-reflective zone in some cases. No lesion enlarged or developed features consistent with active inflammation after a median follow-up time of 0.9 years (range 0-16.8).

Discussion/Conclusion

Optical coherence tomography shows SIC to be an intrascleral lesion. Furthermore, we found no evidence of any inflammatory component. A nomenclature change to idiopathic scleroma is appropriate to prevent unnecessary investigation.

The evolution of an active solitary idiopathic choroiditis (focal scleral nodule): a case report of the natural course and a review of the literature

Background

To describe the clinical course of an active solitary idiopathic choroiditis (focal scleral nodule) that nearly resolved over six weeks without intervention.

Case presentation

An 18-year-old man presented to the emergency department with headaches and new onset central scotoma in the right eye. Visual acuity was 20/20 in both eyes. Fundus examination revealed an amelanotic choroidal lesion with associated shallow subretinal fluid. It measured 6.1 × 6.3 × 1.4mm on A- and B-scan. Evaluation for systemic inflammatory and infectious diseases was negative. A week later, the lesion remained stable, and a month later, there was improvement of the lesion with a decrease in size on OCT and exam and resolution of the subretinal fluid suggesting that the lesion had become inactive.

Conclusions

Solitary idiopathic choroiditis (Focal scleral nodule) is a rare condition characterized by inflammatory granulomatous reaction. This case report sheds light on the unknown natural course of a solitary idiopathic choroiditis (focal scleral nodule).

Focal Scleral Nodule: A New Name for Solitary Idiopathic Choroiditis and Unifocal Helioid Choroiditis

PURPOSE

To evaluate multimodal imaging findings of solitary idiopathic choroiditis (SIC; also known as unifocal helioid choroiditis) to clarify its origin, anatomic location, and natural course.

DESIGN

Multicenter retrospective observational case series.

PARTICIPANTS

Sixty-three patients with SIC in 1 eye.

METHODS

Demographic and clinical data were collected. Multimodal imaging included color fundus photography, OCT (including swept-source OCT), OCT angiography (OCTA), fundus autofluorescence, fluorescein and indocyanine green angiography, and B-scan ultrasonography.

MAIN OUTCOME MEASURES

Standardized grading of imaging features.

RESULTS

Mean age at presentation was 56 ± 15 years (range, 12-83 years). Mean follow-up duration in 39 patients was 39 ± 55 months (range, 1 month-25 years). The lesions measured a mean of 2.4 × 2.1 mm in basal diameter, were located inferior (64%) or nasal to the optic disc, and appeared yellow (53%). No systemic associations were found. The lesions all appeared as an elevated subretinal mass, with OCT demonstrating all lesions to be confined to the sclera, not the choroid. On OCT, the deep lesion margin was visible in 12 eyes with a mean lesion thickness of 0.6 mm. Overlying choroidal thinning or absence was seen in 95% (mean choroidal thickness, 28 ± 35 μm). Mild subretinal fluid was observed overlying the lesions in 9 patients (14%). Retinal pigment epithelial disruption and overlying retinal thinning was observed in 56% and 57%, respectively. OCT angiography was performed in 13 eyes and demonstrated associated choroidal and lesional flow voids. Four lesions (6%) were identified at the macula, leading to visual loss in 1 patient. One lesion demonstrated growth and another lesion showed spontaneous resolution.

CONCLUSIONS

In this largest series to date, multimodal imaging of SIC demonstrated a scleral location in all patients. The yellow and white clinical appearance may be related to scleral unmasking resulting from atrophy of overlying tissues. Additional associated features included documentation of deep margin on swept-source OCT, trace subretinal fluid in a few patients, and OCTA evidence of lesional flow voids. Because of the scleral location of this lesion in every patient, a new name, focal scleral nodule, is proposed.

Choroidal amelanotic tumours: clinical differentiation of benign from malignant lesions in 5586 cases

PURPOSE

To investigate demographics and clinical features of patients with amelanotic choroidal tumours.

DESIGN

Retrospective analysis.

METHODS

Comparison of demographic and clinical features of various amelanotic choroidal tumours based on stratification by patient age, sex and tumour diameter. Included were all patients with amelanotic choroidal tumours evaluated on the Ocular Oncology Service, Wills Eye Hospital, Philadelphia, Pennsylvania, USA, over a 45-year time period.

RESULTS

A total of 5586 amelanotic choroidal tumours in 4638 eyes of 4441 patients were included with a mean age at presentation of 58 years (median 60, range 0.1-100 years). Most patients were white (95%), female (56%) and with unilateral lesion (96%). By comparison, amelanotic melanoma presented at a younger mean age (57 years) compared with metastasis (60 years, p<0.001), nevus (61 years, p<0.001), lymphoma (65 years, p<0.001), sclerochoroidal calcification (70 years, p<0.001) and peripheral exudative haemorrhagic chorioretinopathy (80 years, p<0.001). Melanoma presented at an older mean age compared with osteoma (30 years, p<0.001), granuloma (42 years, p<0.001), haemangioma (49 years, p<0.001) and inflammatory choroidal lesions (49 years, p<0.001). Differences in race and sex were also seen between the various amelanotic choroidal lesions. With few exceptions, amelanotic melanoma had significantly larger basal diameter, greater thickness, more frequent association with subretinal fluid and more often ultrasonographically hollow, compared with other amelanotic choroidal lesions.

CONCLUSION

Understanding the demographic and clinical features of amelanotic choroidal melanoma and other amelanotic lesions could lead to an earlier and more accurate diagnosis.

A Case of Presumed Tuberculosis Uveitis with Occlusive Vasculitis from an Endemic Region

In this report, we present a case with presumed unilateral tuberculosis uveitis from an endemic region. A 23-year-old male presented with decreased vision in his left eye for 15 days. Visual acuities were 1.0 in his right eye and 0.3 in his left eye. Ophthalmologic examination was normal for the right eye. Slit-lamp examination revealed 2+ cells in the vitreous without anterior chamber reaction in his left eye. Fundus examination revealed occlusive vasculitis and granuloma. His history revealed that he had a respiratory infection with fever 3 months ago while visiting his native country, Rwanda, and was treated with non-specific antibiotic therapy. His visual symptom started 2 weeks after his systemic symptoms resolved. Laboratory findings included 15 mm induration in purified protein derivative tuberculin skin test, HIV negativity, and parenchymal lesions in chest X-ray. Bronchoalveolar lavage was negative for acid-fast bacillus. A pulmonary disease consultant reported presumed tuberculosis because of the patient's history. Anti-tuberculosis treatment was initiated. The patient's visual acuity improved rapidly and his signs regressed. A careful history should be taken from patients with uveitis. Travel to tuberculosis-endemic areas may be important for diagnosis and should be asked about directly.

SOLITARY IDIOPATHIC CHOROIDITIS IN THE SETTING OF EXTENSIVE ANIMAL EXPOSURE

PURPOSE

To describe solitary idiopathic choroiditis in the setting of extensive animal exposure.

METHODS

A 56-year-old asymptomatic female equestrian with an extensive history of exposure to horses and dogs and a trapper of wild animals and rodents was discovered to have an amelanotic choroidal mass in the macular region and referred for suspicious atypical nevus.

RESULTS

Funduscopy revealed a deep yellow mass with overlying retinal pigment epithelial thinning and without visible subretinal fluid or lipofuscin. Mild hyperautofluorescence represented unmasking of scleral autofluorescence. Ultrasonography showed a 1.8-mm-thick echodense lesion. Enhanced depth imaging-optical coherence tomography disclosed a dense, elevated scleral mass with "volcanic" configuration, demonstrating choroidal compression and trace overlying subretinal fluid. These features were consistent with solitary idiopathic choroiditis/scleritis. Systemic evaluation for standard cat-related bartonellosis, tuberculosis, sarcoidosis, and syphilis were negative. Horse-, dog-, and rodent-related bartonellosis testing was not available. Observation was advised, and the findings remained stable at 6 months.

CONCLUSION

Solitary idiopathic choroiditis is best imaged on enhanced depth imaging-optical coherence tomography as a scleral lesion with "volcanic" configuration and often secondary to previous Bartonella infection. Serologic positivity for cat-related Bartonella decays over time, and testing for horse-, dog-, or rodent-related Bartonella is not commonly used.

Solitary idiopathic choroiditis

Background

There are multiple conditions associated with the formation of a solitary choroidal granuloma. However, in many cases, solitary choroiditis remains idiopathic in spite of an extensive systemic evaluation.

Methods

A 26-year-old man presented with an asymptomatic pale choroidal lesion that had the features of solitary idiopathic choroiditis.

Results

Optical coherence tomography and fundus autofluorescence were performed and showed lesion features.

Conclusions

Solitary idiopathic choroiditis is a rare condition of unknown aetiology that sometimes can be mistaken as an intraocular tumour. The use of emerging multimodal imaging is of great importance in the diagnosis of this condition.