Nine cases of cavernous hemangioma of the retina

Multimodal imaging of a case of retinal cavernous hemangioma

PURPOSE

Herein, we reported a case of retinal cavernous hemangioma (RCH) and its multimodal imaging.

CASE PRESENTATION

Many grape-like lesions were incidentally found along the distal portion of the vascular arcade in a 23-year-old man's superonasal quadrant of the retina. The best-corrected visual acuity was 20/20 in both eyes. The fluorescein angiography showed saccular lesions that slowly filled with hypofluorescence in the early stage and clusters of aneurysms with hyperfluorescence and a special "fluorescein cap" appearance in the late stage. The optical coherence tomography angiography (OCTA) B-scan revealed multilocular cavernous spaces with different sizes in the inner retinal layers, varying signals, and an epiretinal membrane. The enface OCTA of retina showed grape-like changes and multiple highly reflective signal cavities with clear and complete boundaries.

CONCLUSION

Different multimodal images are better for understanding the characteristics of RCH and more convenient for its diagnosis and follow-up.

Case report: Vitreous hemorrhage as the presenting sign of retinal cavernous hemangioma in a newborn

Purpose

To report a case of vitreous hemorrhage as the presenting sign of retinal cavernous hemangioma (RCH) in a newborn.

Observations

A five-week-old full-term male with a history of seizures and birth trauma underwent ophthalmology screening. Initial eye examination revealed vitreous hemorrhage. Subsequent examination under anesthesia with multi-modal imaging revealed vitreous hemorrhage and an intra-retinal mass with numerous sac-like aneurysmal dilatations, consistent with RCH.

Conclusions and importance

Vitreous hemorrhage in a neonate is an atypical presentation of RCH. Clinicians should be aware that birth trauma may lead to vitreous hemorrhage from RCH. This is the first description of RCH, a rare retinal vascular tumor, in a newborn.

Intraocular Tumors: Angiographic Patterns

Intraocular tumors are primarily diagnosed clinically. However, ancillary tests such as fluorescein angiogram provides excellent visualization of retinal tumors while indocyanine green angiography reveals intrinsic vascular patterns of choroidal tumors. In this review, we contrast angiographic patterns of a variety of retinal, choroidal, and iris tumors.

RETINAL CAVERNOUS HEMANGIOMA WITH INTRALESIONAL PHLEBOLITHS

PURPOSE

To report a case of retinal cavernous hemangioma with intralesional phleboliths, simulating retinoblastoma.

METHODS

A healthy 5-month-old girl developed left esotropia and was noted to have atraumatic vitreous hemorrhage with underlying partially calcified mass, suspicious for retinoblastoma.

RESULTS

On examination, the visual acuity was fix and follow in the right eye and absent fixation in the left eye. Evaluation of the right eye revealed normal findings. The left eye demonstrated healthy anterior segment and dense vitreous hemorrhage with no view of the postequatorial structures, but with hazy view of the flat peripheral retina and a superonasal retinal mass, covered with fresh hemorrhage. Three white intralesional flecks, consistent with calcification, each measuring 300 μm, were visualized. B-scan ultrasonography confirmed the dense mass with several foci of calcification, suspicious for retinoblastoma, despite poor visualization on funduscopy. Prophylactic intravenous chemotherapy was delivered for globe salvage and systemic protection. At 12-month follow-up, the hemorrhage showed resolution, revealing a superonasal dark blue multilobulated mass with saccular aneurysms, measuring 16 mm in diameter, and with 3 phleboliths (intralesional calcification). Fluorescein angiography demonstrated early and midphase hypofluorescence with late-phase filling and with plasma-erythrocyte separation in some larger aneurysms, characteristic of retinal cavernous hemangioma.

CONCLUSION

Retinal cavernous hemangioma can be associated with intralesional calcification (phleboliths).

Noninvasive Structural Imaging of a Retinal Cavernous Hemangioma Using SS-OCTA and Correlation to Previously Reported Histopathology

Optical coherence tomography angiography (OCTA) is a novel imaging modality, and its role in the clinical evaluation of patients remains to be defined. In this report, the authors describe a case of a retinal cavernous hemangioma and show that OCTA of the lesion recapitulates many structural features first described in previous histopathologic studies, including aneurysmal architecture, septated blood flow, and epiretinal membrane. Thus, OCTA provides a new, noninvasive means of studying retinal cavernous hemangioma structure, a unique capability that may also be clinically relevant to the evaluation of other pathologic retinal vascular tumors, such as capillary and racemose hemangiomas. [Ophthalmic Surg Lasers Imaging Retina. 2019;50:e320-e323.].

Analysis of the characteristics of optical coherence tomography angiography for retinal cavernous hemangioma: A case report

RATIONALE

Retinal cavernous hemangioma is a rare congenital vascular malformation with typical fundus changes. Optical coherence tomography angiography (OCTA), which is in rise in the recent years, is a rapid and noninvasive technology to assist in obtaining information regarding the blood flow changes in the fundus lesions from different layers without injecting a contrast agent.

PATIENT CONCERNS

A 40-year-old male patient with visual occlusion in the right eye for >1 month was reported.

DIAGNOSES

Retinal cavernous hemangioma was diagnosed by fundus examination, fluorescein angiography (FA) and OCTA, and the characteristics of OCTA images were analyzed.

INTERVENTIONS

The lesion occurred outside the macula, the central vision remained basically normal, and no significant complications were noted in this patient. Therefore, we preferred to regularly follow-up without therapeutic intervention.

CONCLUSIONS

OCTA can display fundus blood flow and vascular lesions noninvasively and rapidly. On OCTA, retinal cavernous hemangiomas showed characteristic changes and have good correspondence with fundus imaging and FA examinations. Moreover, OCTA remains more sensitive to vascular abnormalities, and imaging remains clearer, providing new diagnosis and follow-up route for this disease.

The American Society of Retina Specialists 2016 Founders Award Lecture

Purpose:

To review the current state of the art of retinal tumors with respect to clinical features, imaging, and management.

Methods:

Review of published literature and personal experience from an ocular oncology service.

Results:

There are several tumors that arise from the sensory retina including those of glial origin (astrocytic hamartoma, acquired astrocytoma, and solitary circumscribed retinal astrocytic proliferation), neural origin (retinoblastoma), and vascular origin (hemangioblastoma, cavernous hemangioma, racemose hemangioma, and vasoproliferative tumor). Most retinal tumors are benign with the exception of retinoblastoma and retinal metastasis. Some retinal tumors are associated with systemic oculoneurocutaneous syndromes such as tuberous sclerosis complex (TSC), 13q deletion syndrome, Von Hippel–Lindau disease, and systemic cavernous and racemose hemangioma syndromes with ocular, cutaneous, neurologic, and other findings. Regarding management, recent data indicate that retinal astrocytic hamartoma and retinal achromic patch are key to the diagnosis of TSC and imply greater risk for brain and kidney tumors. Some children with TSC respond to mammalian target of rapamycin inhibitors, controlling brain, kidney, and eye tumors. Children with retinoblastoma are all screened genetically, and systemic evaluation is provided for detection of metastasis and secondary-related tumors. Newer chemotherapy regimens by intravenous or intra-arterial routes have revolutionized retinoblastoma control. Retinal vascular tumors are uncommon but can have serious systemic implications. Therefore, imaging of the brain for related cerebellar hemangioblastoma, midbrain racemose hemangioma, or multifocal cavernomas is performed. Genetic testing for each disease can be revealing.

Conclusions:

Retinal tumors are often benign, can be recognized by clinical and imaging features, and can be associated with important systemic syndromes.

RETINAL CAVERNOUS HEMANGIOMA DOCUMENTED BY SPECTRAL DOMAIN OPTICAL COHERENCE TOMOGRAPHY AND CONFOCAL SCANNING LASER OPHTHALMOSCOPE RETRO-MODE IMAGING

PURPOSE

To report a case of retinal cavernous hemangioma documented by spectral domain optical coherence tomography and retro-mode retinal imaging by confocal scanning laser ophthalmoscope.

METHODS

Clinical examination, fluorescein angiography, spectral domain optical coherence tomography, and scanning laser ophthalmoscope retro-mode imaging were performed.

RESULTS

Fundus examination of the left eye of an asymptomatic 39-year-old woman showed an irregularly elevated dark red lesion with a cluster of various-sized saccular aneurysms. The retinal cavernous hemangioma lesions were in the upper vascular arcade. A late-phase fluorescein angiography image showed a typical finding, known as fluorescence capping, characterized by incomplete perfusion because of plasma-erythrocyte separation, which was seen in some larger aneurysms. Spectral domain optical coherence tomography showed that various-sized dilated cystic spaces corresponded to the aneurysms. The image showed the horizontal line, which corresponded to the fluorescence capping in some larger aneurysms. Scanning laser ophthalmoscope retro-mode images showed the individual sizes and septum of the aneurysms. The image also showed the characteristic dots-and-lines pattern around the retinal cavernous hemangioma at the corresponding area of inner retinoschisis attributed to the aneurysms without outer retinoschisis on the spectral domain optical coherence tomography images.

CONCLUSION

Spectral domain optical coherence tomography and scanning laser ophthalmoscope retro-mode imaging may be useful for evaluating the pathophysiologic features and the full extent of the retinal cavernous hemangioma.

Macular Cavernous Hemangioma Associated With Peripheral Vascular Anomalies and Nonperfusion

Retinal cavernous hemangiomas are benign vascular anomalies that are typically unilateral and located outside of the macula. Fluorescein angiography findings include an early slow-filling, non-leaking lesion with late intermixed lobules of hyperfluorescence and hypofluoresence secondary to plasma and erythrocyte sedimentation. We present a novel case of unilateral macular cavernous hemangioma with bilateral peripheral vascular anomalies and nonperfusion. This may represent a phenotypic variation of hemangiomas that, in conjunction with recent histopathologic and genetic findings, may aid in future therapies for a disease that has been traditionally observed due to slow progression.

Retinal cavernous hemangioma: fifty-two years of clinical follow-up with clinicopathologic correlation

PURPOSE

To report long-term follow-up and histopathology of a retinal cavernous hemangioma and to review the literature on this subject.

METHODS

A newborn girl was noted immediately after birth to a have hyphema and vitreous hemorrhage in her left eye. The bleeding recurred throughout childhood and the etiology was not determined. Upon referral at age 22, a large retinal cavernous hemangioma was first recognized and recurrent hemorrhages continued, eventually leading to pain and secondary glaucoma. The patient declined treatment. At age 52, the hemangioma was stable in size, but ocular pain and blindness necessitated enucleation.

RESULTS

During the 52-year course, the fundus mass did not enlarge, but numerous episodes of hyphema and vitreous hemorrhage led to chronic glaucoma and eventual blindness. The main histopathologic finding in the disorganized globe was a retinal mass composed of large endothelial-lined vascular channels with thin walls, typical of a retinal cavernous hemangioma. The tumor extended anteriorly into the ciliary body, explaining the recurrent hyphemas. Additional chronic features included extensive fibrosis of the entire anterior segment, iris, and retina with proliferative vitreoretinopathy and widespread intraocular hemosiderosis from chronic hemorrhage. The patient has been free of pain since enucleation.

CONCLUSION

Retinal cavernous hemangioma is a congenital stationary lesion that can cause recurrent intraocular hemorrhage, fibrosis, glaucoma, pain, and blindness, requiring enucleation. Retinal cavernous should be included in the differential diagnosis of childhood hyphema and vitreous hemorrhage.

Current management of Coats disease

Since its original description in 1908, Coats disease has been recognized as an idiopathic cause of severe vision loss with a remarkable diversity in clinical presentation and morphology. Key clinical and imaging variables are helpful in differentiating Coats disease from life-threatening malignancies, and proper management revolves around a thorough knowledge of the differential diagnosis. Despite significant advancement in scientific understanding of the disease process and clinical spectrum, the underlying etiology remains obscure, and both primary and secondary forms are recognized. With the development of anti-VEGF therapy, vitreoretinal specialists have a new, effective adjunct to the clinical management of exudates, macular edema, and serous retinal detachment. We highlight the history, diagnostic challenges, evolving clinical spectrum, and current management of Coats disease.

Vascular tumors of the retina and choroid: diagnosis and treatment

The vascular tumors of the retina and choroid comprise a diverse group of congenital and acquired lesions. The major vascular tumors of the retina include retinal capillary hemangioma, cavernous hemangioma of the retina, retinal vasoproliferative tumor, and racemose hemangiomatosis of the retina or Wyburn–Mason syndrome. Choroidal vascular tumors include circumscribed choroidal hemangioma and diffuse choroidal hemangioma. While classified as benign, visual symptoms secondary to exudative retinal detachment and a variety of other mechanisms are common and are a major source of long-term visual disability. While many therapeutic modalities exist, treatment of symptomatic cases can be challenging. Of particular importance, many of the vascular tumors of the retina and choroid have significant associations with systemic disease. As ocular symptoms are often the most common presenting disease manifestation, the ophthalmologist plays an important role in accurate and early diagnosis. The ability to initiate prompt screening and treatment in appropriate cases is critical. In the following article, the key clinical and diagnostic features of the major retinal and choroidal vascular tumors, their systemic associations, and the literature pertaining to the most currently available treatment strategies are reviewed.

Optical coherence tomography of retinal and choroidal tumors

Optical coherence tomography (OCT) has revolutionized the field of ophthalmology since its introduction 20 years ago. Originally intended primarily for retina specialists to image the macula, it has found its role in other subspecialties that include glaucoma, cornea, and ocular oncology. In ocular oncology, OCT provides axial resolution to approximately 7 microns with cross-sectional images of the retina, delivering valuable information on the effects of intraocular tumors on the retinal architecture. Some effects include retinal edema, subretinal fluid, retinal atrophy, photoreceptor loss, outer retinal thinning, and retinal pigment epithelial detachment. With more advanced technology, OCT now provides imaging deeper into the choroid using a technique called enhanced depth imaging. This allows characterization of the thickness and reflective quality of small (<3 mm thick) choroidal lesions including choroidal nevus and melanoma. Future improvements in image resolution and depth will allow better understanding of the mechanisms of visual loss, tumor growth, and tumor management.

Optical coherence tomography of retinal and choroidal tumors

Optical coherence tomography (OCT) has revolutionized the field of ophthalmology since its introduction 20 years ago. Originally intended primarily for retina specialists to image the macula, it has found its role in other subspecialties that include glaucoma, cornea, and ocular oncology. In ocular oncology, OCT provides axial resolution to approximately 7 microns with cross-sectional images of the retina, delivering valuable information on the effects of intraocular tumors on the retinal architecture. Some effects include retinal edema, subretinal fluid, retinal atrophy, photoreceptor loss, outer retinal thinning, and retinal pigment epithelial detachment. With more advanced technology, OCT now provides imaging deeper into the choroid using a technique called enhanced depth imaging. This allows characterization of the thickness and reflective quality of small (<3 mm thick) choroidal lesions including choroidal nevus and melanoma. Future improvements in image resolution and depth will allow better understanding of the mechanisms of visual loss, tumor growth, and tumor management.

Cavernous hemangioma associated with retinal macrovessels

PURPOSE

The purpose of this study was to report two unusual cases of retinal cavernous hemangiomas in conjunction with retinal macrovessels.

METHODS

Observational case study. Two patients with unilateral retinal cavernous hemangiomas and no signs or symptoms of systemic disease were evaluated with full ophthalmic examination and underwent fundus photography and fluorescein angiography.

RESULTS

Patient 1 had 20/20 visual acuity bilaterally and a normal funduscopic examination of the right eye. The left eye showed diffuse clusters of saccular aneurysms associated with a dilated superotemporal venous arcade that crossed the horizontal raphe temporally. Patient 2 had 20/30 visual acuity in the right eye and 20/20 visual acuity in the left eye. Funduscopic examination of the left eye was normal, but the right eye demonstrated multiple clusters of saccular dilations along the course of a dilated inferior retinal vein that crossed the horizontal raphe temporally. On fluorescein angiography, both patients had fluid-erythrocyte levels within the saccular aneurysms and areas of capillary nonperfusion anterior to the tumor.

CONCLUSION

Retinal cavernous hemangioma is a rare hamartoma that is typically isolated. However, it may be associated with other major abnormalities of the retinal vascular pattern. The authors describe two unique cases of a retinal cavernous hemangioma in conjunction with a retinal macrovessel.

Congenital vascular malformations of the retina and choroid

PURPOSE

To review recent advances in the diagnosis and treatment of congenital vascular malformations of the retina and choroid.

METHODS

Review of the current literature on retinal haemangioblastoma, racemose haemangiomatosis, retinal cavernous haemangioblastoma, circumscribed choroidal haemangioma, and diffuse choroidal haemangioma.

CONCLUSION

The management of patients with congenital vascular lesions of the retina and choroid is advancing rapidly through recent developments in genetic testing, ocular imaging, and treatment. Most are associated with systemic disease, which may be life-threatening. New therapeutic methods such as Verteporfin photodynamic therapy and anti-angiogenic therapy have significantly improved the treatment of retinal and choroidal angiomas and vascular malformations. Ophthalmologists have a major role in detecting and diagnosing these tumours and in providing long-term care in collaboration with a specialist in the field.

[Familial forms of central nervous system cavernomas: from recognition to gene therapy]

Ten percent of all cavernomas are familial forms. 300 independent families have been identified in France since 1995. Clinical manifestations are more frequent in familial (50%) than in sporadic forms (5%). The symptoms are the same in both forms: epilepsy, hemorrhages, neurological focal deficits and headache, but hemorrhages are more frequent and the age of revelation is younger, before 30 years. It is also frequent to observe extraneural location, cutaneous and retinal. On MRI, four types of lesional aspects were described and lesions are multiple in all cases with numerous "de novo" cavernomas. The prognostic does not depend on the number of lesions, but on their topography, especially in the brain stem. Familial forms may be considered not only as a neurological but as a systemic disease for which global management with a genetic counseling should be considered. Gene therapy is not today available, but perhaps in the future.

Genetics of cavernous angiomas

Cerebral cavernous malformations (CCM) are vascular malformations that can occur as a sporadic or a familial autosomal dominant disorder. Clinical and cerebral MRI data on large series of patients with a genetic form of the disease are now available. In addition, three CCM genes have been identified: CCM1/KRIT1, CCM2/MGC4607, and CCM3/PDCD10. These recent developments in clinical and molecular genetics have given us useful information about clinical care and genetic counselling and have broadened our understanding of the mechanisms of this disorder.

Ocular vascular hamartomas: the relationship with phakomatoses and possible commonalities in pathogenesis

BACKGROUND

Ocular vascular hamartomas may present as isolated lesions or as part of a multisystemic congenital syndrome known as vascular phakomatoses. These syndromes are characterized by ocular, cerebral, and cutaneous lesions. Although each of these lesions manifests distinct characteristics, there may be overlapping characteristics and manifestations attributable to a common pathogenesis.

METHODS

A case series and a literature review are presented illustrating ocular and systemic manifestations associated with vascular hamartomas, with each case representing varying degrees of ocular and systemic expression.

CONCLUSION

Because of the potential ocular morbidity and systemic mortality associated with vascular hamartomas and associated syndromes, the optometrist plays an important role in the management of these patients. In general, understanding the pathogenesis of these diseases may contribute to future treatment and prevention opportunities.

A case of central visual loss in a child due to macular cavernous haemangioma of the retina

PURPOSE

To report a case of retinal cavernous haemangioma localized to the fovea.

METHODS

Clinical examination, fluorescein angiographic study and magnetic resonance imaging are reported.

RESULTS

A 9-year-old girl presented with acute loss of vision in the right eye. Ophthalmoscopy showed intraretinal bleeding in the macula, while fluorescein angiography showed a lesion typical of a small cavernous retinal haemangioma, localized in the central macula. Family history was negative.

CONCLUSION

Central cavernous retinal haemangioma is a rare cause of central visual loss and should be distinguished from other retinal vascular abnormalities with more profound systemic implications for the patient.

Twin vessels in familial retinal cavernous hemangioma

We investigated the presence of twin vessels in two patients and in four of their relatives at risk from one family with autosomal-dominant hereditary cavernous hemangioma of the retina associated with central nervous system involvement. Twin vessels were detected in four of the six patients examined. The proband had bilateral retinal vascular hamartomas with central nervous system involvement but no twin vessels. The proband's mother had vascular hamartomas of the retina and brain with twin vessels. In the other three family members, twin vessels were associated either with retinal cavernous hemangiomas (one patient) or with normal fundi (two patients). Because twin vessels may be an ocular manifestation of von Hippel-Lindau disease, their presence in one of our two patients and in the otherwise healthy three family members suggests that twin vessels may be associated with different retinal vascular hamartomas, including capillary and cavernous hemangiomas.