Choroidal neovascularization secondary to choroidal osteoma: successful treatment with photodynamic therapy

Clinical features and therapeutic management of choroidal osteoma: A systematic review

Choroidal osteoma is a benign ossifying tumor within the choroid. Complications associated with choroidal osteoma, including disruption of retinal pigment epithelium, atrophy of photoreceptors, subretinal fluid, and choroidal neovascularization, present challenges for clinicians, and management remain controversial. We performed a comprehensive search in the PubMed, EMBASE, and Ovid databases for published studies and case reports relating to the management of choroidal osteoma. Since it was first described in 1978, various case reports of ocular complications associated with choroidal osteoma have been documented, and various therapies have yielded different outcomes. We systematically evaluate the literature published on this rare entity.

LONG TERM RESULTS OF PHOTODYNAMİC THERAPY IN INTRAOCULAR TUMORS

PURPOSE

To report long term results of photodynamic therapy (PDT) as treatment for intraocular tumors METHODS: Retrospective interventional case series of 15 patients. All patients treated with standard-fluence PDT (83 seconds; 50 J/cm2) using verteporfin.

OUTCOME MEASURES

Tumor diameter, tumor thickness, subretinal fluid resolution, best-corrected visual acuity,intraocular pressure and PDT complications.

RESULTS

10 patients (66.7% of total patients) were diagnosed with choroidal hemangioma, 3 patients (20% of total patients) were diagnosed with choroidal melanoma, and 2 patients (13,3% of total patients) were diagnosed with choroidal osteoma.. Mean follow-up time was 33±18 months. The mean visual acuity was determined as 1.29±0.98 logMAR in the examinations just before the PDT application. At the end of the follow-up period, the mean visual acuity was calculated as 1.41±1.07 logMAR. While VA increased in 3 (20%) patients and decreased in 5 (33.3%) patients; It was determined that VA value did not change after treatment in 7 (46.7%) patients. The mean lesion diameter before PDT was 6573 ±2115 µm (range; 1500-10000µm). The mean tumor thickness before PDT was 3624 ±1404 µm (range; 600-6000µm). The mean lesion diameter after treatment was 6026±2521 µm (range; 0-9000µm), and the mean tumor thickness after treatment was 2280 ±1740 µm (range; 0-6000 µm).After the PDT, tumor size decreased in 8 (53.3%) patients, increased in 3 (20%) patients, and no change in tumor size was observed in 4 (26.7%) patients. Mean IOP values ​​of all patients were 14.06±3.17 mmHg before treatment; after treatment, it was measured as 13.46±1.70 mmHg. After the treatment, geographic atrophy developed in 1 (6.7%) patient, cystoid macular edema developed in 1 (6.7%) patient, Retinal Pigment Epithelium (RPE) and choroidal atrophy developed in 1 (6.7%) patient.

CONCLUSION

There are not enough cases of each to clearly distinguish between these 3 types of ocular cancers however PDT may be a good option in the treatment of intraocular tumors with the chance of selective treatment and successful responses in selected cases.

Secondary choroidal neovascularization due to choroidal osteoma after 9 years follow-up

BACKGROUND

Choroidal osteoma is a benign intraocular tumor that can increase risk of developing choroidal neovascularization. The visual prognosis is influenced by the tumor location, decalcification status, overlying RPE atrophy, presence of choroidal neovascularization, persistence of subretinal fluid and occurrence of subretinal hemorrhages.

CASE PRESENTATION

The authors present a 40-year-old woman diagnosed with choroidal osteoma of the right eye. Her best corrected visual acuity was 12/20 but decreased to 5/20 due to secondary choroidal neovascularization after 8 years follow up. Fundus examination revealed an enlarged choroidal osteoma in most margins at posterior pole with schistose hemorrhage beside macula. Optical coherence tomography angiography revealed unique features in the vascular changes of choroidal neovascularization in choroidal osteoma in the outer retinal layer and choroid capillary layers, and subretinal neovascularization. Indocyanine green fluorescence angiography showed there was hypo-fluorescence at the peripapillary with faint hyper-fluorescence at the macular, corresponding to the location on the fundus photograph. The patient received 3 injections of intravitreal ranibizumab. After 1 year follow up, her visual acuity of the right eye was 18/20 and the CNV had regressed.

CONCLUSIONS

We present the findings and treatment of a case of choroidal osteoma with secondary choroidal neovascularization. Optical coherence tomography angiography combined with FFA and ICGA is used to analysis the characteristics of secondary choroidal neovascularization. Optical coherence tomography angiography can reveal some unique characteristics in the vascular changes compared to fundus fluorescein angiography.

Age-related macular degeneration masqueraders: From the obvious to the obscure

Age-related macular degeneration (AMD) is one of the leading causes of blindness worldwide with increasing prevalence owing to increased life expectancy. Intravitreal injections of antivascular endothelial growth factor agents are commonly used in exudative AMD and oral antioxidant medication for nonexudative AMD; however, many disorders mimic exudative and nonexudative AMD, and misdiagnosis can seriously affect the management of these patients. We summarize the demographics and clinical and imaging characteristics of each of the conditions that masquerade as AMD. As some of the conditions have features of AMD, a short update on the classical features of AMD is also included.

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.

Polypoidal choroidal vasculopathy as a complication of choroidal osteoma: A case report

INTRODUCTION

Choroidal osteoma (CO) is a rare benign tumor that particularly affects young, healthy women. Its prognosis is influenced by complications, such as choroidal neovascularization (CNV), subretinal hemorrhage, subretinal fluid (SF), decalcification status, and overlying retinal pigment epithelium (RPE) atrophy. In case of CNV as the complication of CO, it is typically present in the classic form; however, reports on polypoidal choroidal vasculopathy (PCV) have been rare. Here, we report a case of an older, male patient with PCV as a complication of CO.

PATIENT CONCERNS

A 70-year-old male patient visited the hospital with vision impairment in the right eye since 2 weeks.

DIAGNOSIS

Fundus examination revealed a red-yellow, well-demarcated, scalloped lesion around the optic nerve in each eye; the lesions were highly reflective on ultrasound examination, and thus, CO was diagnosed. Indocyanine green fluorescence angiography and optical coherence tomography (OCT) revealed that the right eye also had PCV accompanied with SF. OCT confirmed the presence of large quiescent type 1 CNV bilaterally in decalcified areas of the lesions adjacent to the optic nerve.

INTERVENTIONS

Intravitreal bevacizumab (IB) injection was performed.

OUTCOMES

Best-corrected visual acuity had improved and OCT showed a decrease in the SF, while OCT angiography showed partial regression of branching vascular network.

CONCLUSION

CO can be accompanied by quiescent type 1 CNV; this should be closely monitored because it can progress to PCV. Optical coherence tomography, alongside indocyanine green fluorescence angiography, is useful for the diagnosis and monitoring of potential CNV as a complication of CO.

The Role of Steroids and NSAIDs in Prevention and Treatment of Postsurgical Cystoid Macular Edema

BACKGROUND

Pseudophakic cystoid macular edema (PCME) remains one of the most common visionthreatening complication of phacoemulsification cataract surgery (PCS). Pharmacological therapy is the current mainstay of both prophylaxis, and treatment of PCME in patients undergoing PCS. We aimed to review pharmacological treatment options for PCME, which primarily include topical steroids, topical nonsteroidal antiinflammatory drugs (NSAIDS), periocular and intravitreal steroids, as well as anti-vascular endothelial growth factor therapy.

METHODS

The PubMed and Web Of Science web platforms were used to find relevant studies using the following keywords: cataract surgery, phacoemulsification, cystoid macular edema, and pseudophakic cystoid macular edema. Of articles retrieved by this method, all publications in English and abstracts of non-English publications were reviewed. Other studies were also considered as a potential source of information when referenced in relevant articles. The search revealed 193 publications. Finally 82 articles dated from 1974 to 2018 were assessed as significant and analyzed.

RESULTS

Based on the current literature, we found that corticosteroids remain the mainstay of PCME prophylaxis in uncomplicated cataract surgery, while it is still unclear if NSAID can offer additional benefits. In patients at risk for PCME development, periocular subconjunctival injection of triamcinolone acetonide may prevent PCME development. For PCME treatment the authors recommend a stepwise therapy: initial topical steroids and adjuvant NSAIDs, followed by additional posterior sub-Tenon or retrobulbar corticosteroids in moderate PCME, and intravitreal corticosteroids in recalcitrant PCME. Intravitreal anti-vascular endothelial growth factor agents may be considered in patients unresponsive to steroid therapy at risk of elevated intraocular pressure, and with comorbid macular disease.

CONCLUSION

Therapy with topical corticosteroids and NSAIDs is the mainstay of PCME prophylaxis and treatment, however, periocular and intravitreal steroids should be considered in refractory cases.

Choroidal Osteoma and Secondary Choroidal Neovascularization Treated with Ranibizumab

A 47-year-old female patient presented with a complaint of decreased vision in the right eye. Her visual acuity was 0.16 in the right eye and 1.0 in the left eye. Fundus examination revealed a slightly elevated, yellowish-white lesion with regular borders at the macula of the right eye. Early and late hyperfluorescence related with choroidal neovascularization (CNV) was detected in the right eye on fundus fluorescein angiography. B-scan ultrasonography revealed a hyperechoic choroidal lesion with acoustic shadowing. The lesion was diagnosed as choroidal osteoma. The patient received 3 injections of intravitreal ranibizumab. After 4 months, the visual acuity of the right eye was 0.9 and the CNV had regressed. Follow-up at about 7 months revealed reduced visual acuity in the right eye with an increase in subretinal fluid. An additional ranibizumab injection was administered. In this case report, we discuss the findings and treatment of a rare case of choroidal osteoma with secondary CNV.

Intravitreal bevacizumab monotherapy for choroidal neovascularisation secondary to choroidal osteoma

PurposeThe purpose of this study is to present the outcomes of a series of patients with choroidal neovascular membrane (choroidal neovascularisation (CNV)) secondary to a choroidal osteoma undergoing anti-VEGF monotherapy.Patients and methodsRetrospective series of patients with choroidal neovascularization secondary to choroidal osteoma. All patients underwent clinical and imaging assessment (fundus photo, B-scan ultrasonography, fluorescein angiography, and optical coherence tomography-where available), and were managed with intravitreal anti-VEGF injections (Bevacizumab). Visual acuity and central retinal thickness were recorded pre treatment and at the end of the follow-up period.ResultsEight patients were included in this study. Of this, 6/8 had predominantly classic or classic and 2/8 patients had minimally classic or occult CNV. Each patient received 3-10 injections of bevacizumab. Median follow-up was 9 months (3-15 months). Visual acuity improved in 5 patients, by 2-6 Snellen lines. CNV completely regressed in 5 cases and partially regressed in 3 cases. Mean CRT reduction was 122 μm (6 to -230 μm).ConclusionIntravitreal bevacizumab can be an effective treatment modality in the management of vision threatening CNV secondary to choroidal osteoma.

Bilateral Multifocal Choroidal Osteoma with Choroidal Neovascularization

Choroidal osteoma has been reported to be unilateral in approximately 80% of cases diagnosed with this condition. Herein we report the clinical characteristics and multimodal imaging findings in a rare case of bilateral multifocal choroidal osteoma. A 32-year-old female presented with decreased visual acuity (VA) in the right eye (20/100), though she had normal VA (20/20) in the left eye. Ophthalmoscopy and multimodal imaging investigation revealed bilateral multifocal choroidal osteoma complicated by choroidal neovascularization (CNV) in the right eye. Following three injections of intravitreal bevacizumab (IVB) for CNV in the right eye, VA improved to 20/40.

Real-time in vivo micromorphology and histopathology of choroidal osteoma using enhanced depth imaging

Choroidal osteoma is a usually unilateral benign tumor of the choroid composed of mature bone. Optical coherence tomography (OCT) has been used to image osteoma for several years. With the advent of enhanced depth imaging (EDI) feature of spectral-domain OCT (SD-OCT), better visualization of the morphology of choroidal lesions has been possible. Herein we present a case of choroidal osteoma in a 45-year-old woman, wherein in vivo morphology of the choroidal osteoma had been visualized using EDI technique of SD-OCT before and after performing photodynamic therapy. EDI OCT has proven to be a valuable noninvasive imaging modality, almost comparable to histopathological examination, for diagnosing choroidal osteomas and for providing an insight into the in vivo micromorphological changes occurring during the course of the disease.

Review of choroidal osteomas

Choroidal osteomas are rare benign ossifying tumors that appear as irregular slightly elevated, yellow-white, juxtapapillary, choroidal mass with well-defined geographic borders, depigmentation of the overlying pigment epithelium; and with multiple small vascular networks on the tumor surface. Visual loss results from three mechanisms: Atrophy of the retinal pigment epithelium overlying a decalcified osteoma; serous retinal detachment over the osteoma from decompensated retinal pigment epithelium, and most commonly from choroidal neovascularization. Recent evidence points to the beneficial effects of intravitreal vascular endothelial growth factor antagonists in improving visual acuity in serous retinal detachment with or without choroidal neovascularization.

Role of Intravitreal Antivascular Endothelial Growth Factor Injections for Choroidal Neovascularization due to Choroidal Osteoma

We treated 26 eyes of 25 young patients having a mean age of 30 years with intravitreal vascular endothelial growth factor (VEGF) inhibitor for choroidal new vessel (CNV) formation overlying choroidal osteoma over a mean follow-up of 26 months. Mean number of injections was 2.4 at 6 months, 3.2 at 12 months, and 5.5 at 24 months. CNV was subfoveal in 14 eyes, juxtafoveal in 5, extrafoveal in 5, and peripapillary in 2. By paired comparison, mean decrease from baseline was 119.7 microns at 6 months (n = 15; P = 0.001), 105.3 microns at 1 year (n = 10; P = 0.03), and 157.6 microns at 2 years (n = 7; P = 0.08). BCVA improved by 3.3 lines at 6 months after therapy (n = 26; P < 0.001), 2.8 lines (n = 20; P = 0.01) at 1 year, and 3.1 lines (n = 13; P = 0.049) at 2 years. We conclude that intravitreal anti-VEGF injections improve vision in majority of eyes with CNV from choroidal osteoma.

[Choroidal osteoma]

Choroidal osteoma is a rare benign osseous tumor of the choroid usually affecting young healthy women. The diagnosis can be confirmed by the clinical appearance and with use of fluorescein or indocyanine angiography, optical coherence tomography, computed tomography or magnetic resonance imaging. A direct therapy of the tumor is indicated only for a few cases. The main reasons for vision loss are choroidal neovascularization, subretinal fluid and changes in the photoreceptor layer or the retinal pigment epithelium. Choroidal neovascularization and subretinal fluid in particular can be treated with laser therapy, photodynamic therapy or vascular endothelial growth factor inhibitors.

[Intravitreal injection of bevacizumab for CNV secondary to choroidal osteoma and follow-up by Spectral-Domain OCT]

BACKGROUND

Choroidal osteoma is a rare, ossifying tumor, which, while benign, may be complicated by choroidal neovascularization.

METHODS

An 11-year-old boy presented with blurred vision in the right eye for few days. Fundus examination showed bulky lesion in the posterior pole containing a sub-retinal hemorrhage. The geographic borders and color of the mass were typical of choroidal osteoma despite the unusual macular location. The diagnosis was confirmed by ultrasonography. The patient was treated with three successive intravitreal injections of 1.25 mg/0.05 mL bevacizumab (IVB) under general anesthesia, due to recurrences of neovascular activity. SD-OCT in EDI mode was carried out prior to each injection.

RESULTS

SD-OCT before and after each bevacizumab injection confirmed regression of serous retinal detachment (SRD) at various locations throughout the lesion, especially in the hemorrhagic zone. It also allowed us to differentiate the active decalcified zones from the inactive calcified zones and to follow treatment response.

DISCUSSION

The treatment of choroidal neovascularization (CNV) secondary to choroidal osteoma is not well defined. As for other etiologies of CNV, anti-VEGF agents (such as bevacizumab) appear to be effective in regressing CNV and improving visual function. In our young patient, general anesthesia was necessary to administer each injection. SD-OCT allows diagnostic confirmation and follow-up of treatment. EDI mode is helpful in studying the choroid and the osteoma.

CONCLUSION

We report a rare case of macular choroidal osteoma, examined by SD-OCT. CNV required several anti-VEGF injections, with good anatomical and functional results.

Long-term success of intravitreal bevacizumab for choroidal neovascularization associated with choroidal osteoma

PURPOSE

To describe a case of choroidal osteoma with choroidal neovascularization (CNV) that was successfully treated with two intravitreal injections of bevacizumab (IVB).

DESIGN AND METHODS

Case report on a 12-year-old Japanese girl who presented with a sudden decrease in vision in her left eye. At the first visit, 2 days after the onset of her symptoms, her visual acuity (VA) in her left eye was 0.2. Ophthalmoscopy showed a hemorrhage of 5 disc diameters under the retinal pigment epithelium and a serous retinal detachment at the posterior pole of the left eye. These findings were confirmed by optical coherence tomography. Fluorescein angiography (FA) and indocyanine green angiography (ICGA) showed several points of leakage around the fovea, which suggested a CNV. From these findings, the patient was diagnosed with choroidal osteoma with a CNV. The submacular hemorrhage was from the CNV associated with the choroidal osteoma. We treated her with two injections of 1.25 mg/0.05 mL IVB with a 4-month interval.

RESULTS

The patient's VA in her left eye improved to 0.7, and this vision was maintained for 4 years. The CNV disappeared in the FA and ICGA images and no recurrence was observed after 4 years.

CONCLUSION

Our findings indicate that IVB is effective in resolving CNV in eyes with an osteoma and prevents a decrease of vision in eyes with a choroidal osteoma with a CNV.

Bilateral choroidal osteomas with polypoidal choroidal vasculopathy

BACKGROUND

A choroidal osteoma is a benign osseous tumor typically arising in the juxtapapillary or peripapillary area. The major cause of visual loss is secondary to the development of a subretinal neovascular membrane. The pattern of neovascularization that develops with osteomas has been typically described as classic choroidal neovascularization (CNV).

METHODS

Interventional case report.

RESULTS

A case of bilateral polypoidal choroidal neovascularization (PCV) occurring with bilateral choroidal osteomas is described in a 55-year-old Japanese woman. To our knowledge, this variant form of vasogenesis has not previously been described in association with this tumor. Clinical, angiographic, and optical coherence tomographic features are discussed. Subretinal hemorrhage in the left eye from polypoidal neovascularization in the macula was successfully treated with photodynamic therapy.

CONCLUSIONS

The association between choroidal osteoma and PCV may have a better prognosis than that with classic CNV. Indocyanine green angiography is a useful tool in characterizing the nature of the neovascularization.

Dramatic response of choroidal neovascularization associated with choroidal osteoma to the intravitreal injection of bevacizumab (Avastin)

PURPOSE

To report the dramatic response of juxtafoveal choroidal neovascularization (CNV) associated with choroidal osteoma to a single intravitreal injection of bevacizumab.

METHODS

A 19-year-old female presented with decreased visual acuity and metamorphopsia in her right eye. Best corrected visual acuity assessment, ophthalmic examination, fundus photography, fluorescein angiography, optical coherence tomography (OCT), and high-resolution computed tomography (CT) scan of the orbit was performed. A diagnosis of classic juxtafoveal CNV associated with choroidal osteoma was made. Intravitreal injection of 1.25 mg of bevacizumab was performed.

RESULTS

Visual acuity of the right eye was 20/200 before treatment. Visual improvement to 20/25 and the resolution of metamorphopsia was noticed six weeks after the intravitreal injection of bevacizumab. Regression of the CNV was confirmed according to ophthalmoscopic, fluorescein angiographic, and OCT findings. The treatment effect persisted during a 9-month follow-up period.

CONCLUSION

The intravitreal injection of bevacizumab can result in the rapid regression of CNV secondary to choroidal osteoma.

Choroidal osteoma: evidence of progression and decalcification over 20 years

Choroidal osteoma is a rare, benign, ossifying tumour of the choroid of unknown aetiology. In contrast to other types of intraocular ossification, choroidal osteoma is found typically in young healthy females in the second or third decades of life with no history of systemic or ocular disease. Choroidal osteoma is a deep, pale yellow lesion with distinct geographic borders at the juxtapapillary or macular region, with branching 'spider' vessels on the surface of the tumour. These features should help differentiate choroidal osteoma from other types of intraocular tumour and the diagnosis can be confirmed with ultrasonography and computerised tomography. Here we report an initially unilateral case of choroidal osteoma, which decalcified over 20 years but during the same period the fellow eye also developed a choroidal osteoma to become a bilateral case. Despite the benign nature of the tumour, vision may be compromised by gradual atrophy of the overlying retina, serous retinal detachment, accumulation of sub-retinal fluid and sub-retinal haemorrhage associated with choroidal neovascularisation. Frequent examinations are recommended for patients with choroidal osteoma, for early detection of a subretinal neovascular membrane and potential treatment with laser photocoagulation.