Fundus changes associated with congenital hypertrophy of the retinal pigment epithelium

Congenital focal abnormalities of the retina and retinal pigment epithelium

This paper reviews the published literature on a group of developmental disorders of the retina and retinal pigment epithelium which result in focal abnormalities in one or both eyes. They are often asymptomatic, found on routine examination and are generally non-progressive. Some are associated with other systemic abnormalities.

From an asymptomatic lesion to a vision-threatening condition: Congenital hypertrophy of the retinal pigment epithelium complicated by choroidal neovascular membrane

We reported a case of congenital hypertrophy of the retinal pigment epithelium (CHRPE) complicated by choroidal neovascular membrane (CNVM). A 41-year-old woman presented to our clinic with visual loss in the left eye. She was diagnosed as CHRPE complicated by a CNVM. The patient was treated with 2 consecutive monthly intravitreal aflibercept (IVA) injections. The best-corrected visual acuity (BCVA) improved and stabilized at 6/6. Subretinal fluid depending on CNVM resolved completely. CHRPE complicated by CNVM in the macular area is a rare condition and these cases can be treated with IVA therapy.

Ocular coherence tomography angiography features of congenital hypertrophy of retinal pigment epithelium

Congenital hypertrophy of retinal pigment epithelium (CHRPE) is a benign, pigmented, flat lesion arising from the retinal pigment epithelium (RPE). In this study, we describe optical coherence tomography angiography (OCTA) features of two eyes with solitary CHRPE. We found that the retinal vasculature over CHRPE was normal in both cases. We observed that in solitary CHRPE, segmentation artifacts can interfere in the interpretation of retinal vasculature due to thinning of the outer retina. Visualization of the underlying choroidal vasculature was obscured to some extent by masking effect of the hyperpigmented RPE. The choroidal vasculature was better appreciated on en face OCTA. On OCTA, the retinal and choroidal vasculature associated with CHRPE was found to be normal in our study.

Indocyanine Green Angiography in Congenital Hypertrophy of the Retinal Pigment Epithelium

PURPOSE

To report a case of congenital hypertrophy of the retinal pigment epithelium followed up for 7 years showing features not previously reported.

METHODS

A complete fundus examination including fluorescein angiography was performed at first examination and at follow-up.

RESULTS

The area of congenital hypertrophy of the retinal pigment epithelium presented morphologic changes, showing enlargement of the lesion on one side associated with partial regression on another side. In addition, the indocyanine green angiography findings revealed that this test was more useful than fluorescein angiography to delineate the real boundaries of the lesion and disclosed hypofluorescent areas inside the main lesion that were not appreciated at ophthalmoscopy or fluorescein angiography.

CONCLUSIONS

Indocyanine green angiography is an useful test to understand the findings and evolution of congenital hypertrophy of the retinal pigment epithelium.

Tumors and Related Lesions of the Pigmented Epithelium

Several tumors and pseudotumors can arise from the iris pigment epithelium (IPE), ciliary pigment epithelium (CPE), and retinal pigment epithelium (RPE), including cysts of the IPE, solitary congenital hypertrophy of the RPE (CHRPE), multifocal CHRPE ("bear tracks"), congenital simple hamartoma of the RPE, combined hamartoma of the retina and RPE, and acquired epithelioma of IPE, CPE, and RPE. This article describes examples of pigment epithelial tumors and pseudotumors by reviewing the literature and cases on file in the Oncology Service at Wills Eye Hospital. Solitary CHRPE, traditionally believed to be stationary, can show growth in diameter in 83% and can spawn elevated nodular tumors that can progressively enlarge, cause complications, and even evolve into malignant epithelioma (adenocarcinoma). Multifocal CHRPE (congenital grouped pigmentation) has no relationship to familial adenomatous polyposis or Gardner syndrome, despite its similarity to the pigmented fundus lesions seen with those conditions. Congenital simple hamartoma of the RPE is a specific lesion that involves the fovea and does not tend to cause complications. Combined hamartoma, an idiopathic proliferation of RPE cells, blood vessels, and glial cells, is also believed to be a relatively stable lesion but can cause vision loss due to traction. Acquired tumors (adenoma, adenocarcinoma) have features distinct from melanoma clinically and histopathologically. Torpedo maculopathy is a small stable lesion with typical features, resembling a torpedo. There are several intriguing tumors and pseudotumors of the pigmented epithelium that have major clinical and histopathologic importance.

Solitary congenital hypertrophy of the retinal pigment epithelium features by high-definition optical coherence tomography

PURPOSE

To describe the features of solitary congenital hypertrophy of the retinal pigment epithelium (CHRPE) using high-definition optical coherence tomography (HD-OCT).

METHODS

This was a retrospective, observational, noncomparative case series including 16 consecutive patients with solitary CHRPE. We describe the clinical and OCT features of CHRPE using the 5 radial lines acquisition OCT protocol over the CHRPE and the retina next to the tumor.

RESULTS

The mean patient age was 54 years (median 57 years; range 8-76 years). The CHRPE lesion was outside the posterior pole in 14 of the patients (8 temporal, 3 superior, 2 nasal, and 1 inferior quadrant) and 2 peripapillary. Fifteen patients (94%) showed retinal thinning and complete photoreceptor loss overlying the CHRPE. The RPE hyperreflectivity was found in all patients. The retina over the lesion measured a mean of 60.3% (range 41%-95%) of the thickness of the adjacent normal retina.

CONCLUSIONS

High-definition OCT showed retinal thinning, photoreceptor loss, and RPE hyperreflectivity in solitary CHRPE lesions.

Congenital hypertrophy of the retinal pigment epithelium complicated by a choroidal neovascular membrane

A 66-year-old woman presenting with a history of visual loss in her left eye was diagnosed with congenital hypertrophy of the retinal pigment epithelium accompanied by a choroidal neovascular membrane (CNVM) affecting the macula. Visual acuity improved after 2 treatments of verteporfin photodynamic therapy. Recurrent CNVM in the same eye 3 years later was stabilized and vision slowly improved with a series of intravitreal bevacizumab injections.

Growth of congenital hypertrophy of the retinal pigment epithelium over 22 years

Congenital hypertrophy of the retinal pigment epithelium is traditionally perceived as a stable fundus lesion. A 2 year old was observed for 22 years with noted enlargement in the congenital hypertrophy of the retinal pigment epithelium lesion. Fundus photography confirmed growth from 2 to 4.25 mm in diameter.

Fluorescein Angiographic Features of the Congenital Hypertrophy of the Retinal Pigment Epithelium in the Familial Adenomatous Polyposis

PURPOSE

To asses the prevalence of fluorescein angiographic features in bilateral and multifocal Congenital Hypertrophy of the Retinal Pigment Epithelium (CHRPE) in patients with a diagnosis of familial adenomatous polyposis.

METHODS

We performed prospective angiographic and clinical examination of 49 CHPRE lesions in 15 patients.

RESULTS

About 77.5% of CHRPE lesions were close to retinal vessels. The retinal vascular changes observed overlying and surrounding the CHRPE were: capillary non-perfusion with an area greater than 0.5 disc diameters (41%), capillary microaneurysms (4%), chorioretinal anastomoses (6.2%), attenuation of retinal vessels (4%), choriocapillary vessels inside the lacunae (6.2%) and in the depigmented marginal halo (18.4%). Depigmented streaks in contact with one or both edges of the CHRPE were observed in 79.6% of the lesions. About 9.6% of the lesions were not seen on ophthalmoscopy and could only be detected by angiography.

CONCLUSIONS

Even though the diagnosis of CHRPE is clinical, fluorescein angiography may be useful in confirming the diagnosis, as well as detecting additional lesions not seen by means of ophthalmoscopic examination.

Photoreceptor loss overlying congenital hypertrophy of the retinal pigment epithelium by optical coherence tomography

OBJECTIVE

To describe the cross-sectional retinal anatomy overlying congenital hypertrophy of the retinal pigment epithelium (CHRPE) using optical coherence tomography (OCT).

DESIGN

Retrospective, observational, noncomparative case series.

PARTICIPANTS

Ten consecutive patients with CHRPE.

MAIN OUTCOME MEASURES

The main outcome measures were retinal and retinal pigment epithelium (RPE) thickness relative to normal tissue and the status of the retinal layers, in particular the photoreceptor layer.

RESULTS

The median patient age was 36 years (mean, 34 years; range, 7-56 years). The CHRPE was within 6 mm of the optic disc or foveola in all patients. All patients showed retinal thinning and complete photoreceptor loss overlying the CHRPE. The sensory retina measured a mean of 68% of normal thickness (range, 47%-87%). Of the 8 patients with pigmented CHRPE, the CHRPE was 52% thicker than adjacent RPE. All 8 patients with pigmented CHRPE showed moderate relative shadowing of the underlying choroid. The 2 patients with nonpigmented CHRPE, presumed to represent large lacunae with thin CHRPE rim, showed absent RPE and increased transmission of light, not shadowing, into the choroid by OCT. Both patients with visual field testing showed a visual field defect corresponding to the photoreceptor loss.

CONCLUSIONS

Using OCT, overlying retinal thinning and photoreceptor loss directly over CHRPE was found in 10 consecutive patients. These findings likely account for related visual field loss.

Topographical distribution of typical unifocal congenital hypertrophy of retinal pigment epithelium

PURPOSE

To describe the topographical distribution of typical congenital hypertrophy of retinal pigment epithelium (CHRPE) lesions in the ocular fundi.

METHODS

Retrospective review of the clinical records of 52 patients with typical unifocal CHRPE.

RESULTS

The 52 CHRPE lesions ranged from 2.5 mm to 11.5 mm in maximal basal diameter (mean=6.6 mm, SD=2.6 mm). The central point of the lesion was in the peripheral fundus in 44 eyes and in the intermediate fundus in eight eyes. The footprint of the lesion involved the peripheral fundus only in 25 eyes, both the intermediate and peripheral fundus in 22 eyes, and the intermediate fundus only in five eyes. The central point of the lesion was located in the temporal quadrant in 24 eyes, the inferior quadrant in 12 eyes, the nasal quadrant in nine eyes, and the superior quadrant in seven eyes. No lesion in this series involved the posterior fundus.

CONCLUSIONS

The most common fundus location for typical unifocal CHRPE in this series was the peripheral fundus temporally. Although posterior fundus location of CHRPE has been reported occasionally, our study suggests that such a location is very uncommon.

Pseudomelanomas of the posterior uveal tract: the 2006 Taylor R. Smith Lecture

PURPOSE

To determine the types and frequency of lesions that clinically simulate choroidal or ciliary body melanoma (posterior uveal melanoma; PUM).

PATIENTS AND METHODS

A review was conducted on cases of patients referred to the ocular oncology service from October 1978 through September 2003 with the diagnosis of possible PUM but who were subsequently diagnosed by the authors to have a simulating lesion rather than PUM. The type and percent of pseudomelanomas were tabulated and compared with findings of a similar study from our service on data collected before 1978.

RESULTS

There were approximately 12,000 patients referred because of a lesion believed to be a PUM during the 25 years included in the data collection. Of these patients, 1,739 (14%) were found to have a simulating condition. There were 54 different conditions that simulated melanoma. The most frequent condition was choroidal nevus, accounting for 851 cases (49%) of the pseudomelanomas. This was followed by peripheral exudative hemorrhagic chorioretinopathy (139 cases; 8%), congenital hypertrophy of the retinal pigment epithelium (108 cases; 6%), hemorrhagic detachment of the retina or pigment epithelium (86 cases; 5%), circumscribed choroidal hemangioma (79 cases; 5%) and age-related macular degeneration (76 cases; 4%). Compared with the 1980 report, the rate of pseudomelanomas diagnosed as choroidal nevus increased from 26% to 49%.

CONCLUSION

A variety of lesions can simulate PUM. Suspicious choroidal nevus is still the lesion most difficult to differentiate from PUM. Most other pseudomelanomas account for a lower percent compared with findings from the prior study, suggesting that clinicians are now more familiar with the other pseudomelanomas and less likely to refer them to rule out PUM.

Adenocarcinoma arising from congenital hypertrophy of the retinal pigment epithelium

BACKGROUND

Adenocarcinoma of the retinal pigment epithelium (RPE) is a rare primary malignant intraocular neoplasm. We report a histopathologically confirmed case of adenocarcinoma of the retinal pigment epithelium arising from congenital hypertrophy of the retinal pigment epithelium (CHRPE).

METHODS

The clinical features, surgical management, and histopathological features of a melanotic tumor arising from CHRPE are presented. The tumor was excised by transcleral resection.

RESULTS

Histopathological and immunohistochemical study of the tumor showed it to be an adenocarcinoma of the RPE.

CONCLUSIONS

Adenocarcinoma of the RPE arising from CHRPE is extremely rare. Such a tumor can resemble a choroidal melanoma. In spite of the rarity of this association, periodic monitoring of CHRPE for development of a nodular tumor of the RPE is probably warranted.

Solitary congenital hypertrophy of the retinal pigment epithelium

OBJECTIVE

To describe the clinical features of solitary congenital hypertrophy of the retinal pigment epithelium (CHRPE) and to determine the frequency of enlargement of this lesion

DESIGN

Retrospective, observational, noncomparative case series.

PARTICIPANTS

Three hundred thirty consecutive patients with solitary CHRPE.

MAIN OUTCOME MEASURES

The 3 main outcome measures included flat lesion enlargement, intralesional lacunae enlargement, and development of an elevated nodule within the lesion. The clinical features at the time of presentation were analyzed for their impact on the main outcomes using a series of Cox proportional hazards regressions.

RESULTS

The most common referring diagnosis included choroidal nevus (26%), choroidal melanoma (15%), CHRPE (9%), and unspecified lesion (48%). The median age at diagnosis was 45 years (range, 1-80 years), and there were no patients with familial adenomatous polyposis or related colon cancer, although a history of cancer was noted in 8% of patients, most commonly breast cancer (3%). The lesion most frequently was located inferotemporally (31%) and at the equatorial region (45%). Rarely, it was located in the macula (1%) or peripapillary region (1%). The median largest basal diameter was 4.5 mm, and the lesion was flat in all cases except in 5 (1.5%), in which there was an intralesional lesion nodule. The lesion was pigmented in 88% of cases and nonpigmented in 12%. Lacunae were noted in 43% of the pigmented CHRPE, and the lacunae showed gradual enlargement in 32%. Factors related to lacunae enlargement included number and relative size of lacunae. Flat enlargement of the lesion was documented in 46% of patients with comparative photographic follow-up and in 83% of those followed up for more than 3 years. The median rate of enlargement was 10 micro m per month. The most important factor associated with flat lesion enlargement was relative size of the lacunae within CHRPE. There were no cases of CHRPE in which a nodule developed while the patient was being followed up. Of the 5 lesions that had a nodule, progressive enlargement of the nodule was found in 3.

CONCLUSIONS

Congenital hypertrophy of the retinal pigment epithelium generally has been regarded as a benign, stable lesion, but subtle, flat enlargement was noted in most patients (83%) followed up for 3 or more years using meticulous photographic comparison. Flat enlargement of the lesion appeared to be related to percentage of the mass occupied by lacunae.

Diagnostic value of fundus examination in familial adenomatous polyposis

BACKGROUND

Multiple, bilateral lesions of congenital hypertrophy of the retinal pigment epithelium (CHRPE) have been described in patients suffering from familial adenomatous polyposis (FAP) since 1980. This study aimed to determine a reliable diagnostic criterion, based on the size and number of retinal CHRPE lesions, allowing the screening of patient carriers of the gene responsible for FAP.

METHODS

32 control subjects and 144 patients belonging to 85 FAP families were studied, divided into 124 carriers of the genetic alteration and 20 non-carriers.

RESULTS

In carriers of the deleted gene, multiple, bilateral retinal lesions were consistently observed. Lesion situation, size, shape, and degree of pigmentation were variable however. A positive criterion for FAP was defined as the presence of at least four lesions whatever their size, or at least two lesions one of which is large. This criterion showed a high sensitivity (0.68) and a maximal specificity (1). Within each family, the retinal phenotypic expression was homogeneous. CHRPE lesions were observed in two thirds of the FAP families and absent from the remaining third.

CONCLUSION

By using this new positive diagnostic criterion, fundus examination allows early detection of those children carrying the gene responsible for FAP in families positive at ocular examination.

Restriction of ocular fundus lesions to a specific subgroup of APC mutations in adenomatous polyposis coli patients

In humans, alteration of the tumor suppressor gene, APC, causes adenomatous polyposis coli, a condition causing predisposition to colorectal cancer. The syndrome inconsistently associates characteristic patches of congenital hypertrophy of the retinal pigment epithelium (CHRPE). Ocular examination revealed that patients expressing CHRPE tend to cluster within specific families. The exact APC mutation was identified in 42 unrelated patients. In all cases these mutations were predicted to lead to the synthesis of a truncated protein. The extent of CHRPE was found to be dependent on the position of the mutation along the coding sequence. CHRPE lesions are almost always absent if the mutation occurs before exon 9, but are systematically present if it occurs after this exon. Thus, the range of phenotypic expression observed among affected patients may result in part from different allelic manifestations of APC mutations.