RETINAL ASTROCYTIC HAMARTOMA: Optical Coherence Tomography Classification and Correlation With Tuberous Sclerosis Complex

Multimodal Analysis of the Retinal Manifestations of Tuberous Sclerosis Complex: A Case Series

BACKGROUND AND OBJECTIVE

We used a multi-modal imaging approach including fundus fluorescein angiography (FFA) to assess the retinal lesions in tuberous sclerosis complex (TSC) and evaluate their correlation with intracranial tuber burden on magnetic resonance imaging (MRI).

PATIENTS AND METHODS

Participants with TSC underwent bilateral fundus photography, optical coherence tomography (OCT), infrared (IR) imaging, and FFA. Participants' most recent MRI brain scans were analyzed to determine intracranial tuber load.

RESULTS

Nine participants were included. OCT identified all retinal astrocytic hamartoma (RAH) lesions, IR identified 75%, fundus photography identified 63%, and FFA detected just 57%. On FFA, 20% of flat-type hamartomas and all multi-nodular and transitional types were hyperfluorescent. There were significant positive correlations between the quantities of intracranial tubers and all TSC-retinal lesions (r = 0.8, P < 0.01) and all RAH lesions (r = 0.8, P = 0.01).

CONCLUSIONS

A multimodal imaging-based approach with fundal photography, IR imaging, and OCT should be used to assess the retina in TSC as it may indicate the intracranial tuber burden. [Ophthalmic Surg Lasers Imaging Retina 2024;55:568-574.].

Benign Lobular Inner Nuclear Layer Proliferations of the retina

PURPOSE

Report the clinical and imaging findings of a patient with an intraretinal benign tumor that was documented as an unexpected clinical finding after an ischemic stroke in the context of mitral valve disease. This tumor must be distinguished from retinoblastoma and other malignant neoplasms.

METHODS

A patient with intraretinal tumor of the inner nuclear layer (INL) underwent a combination of ophthalmic examination, fundus photography, fluorescein angiography, optical coherence tomography (OCT), and optical coherence tomography angiography (OCT-A).

RESULTS

A 64-year-old male patient with unilateral benign tumor lesions dependent on the internal retina, centered in the posterior pole, and multifocal. OCT showed that these lesions were centered within the INL at the edge of the inner plexiform layer and were not associated with other findings in the posterior pole.

CONCLUSIONS

Benign Lobular Inner Nuclear Layer Proliferations (BLIP) of the Retina are recently described lesions that should be considered, given their distinctive characteristics that set them apart from other benign and malignant retinal lesions.

Role of optical coherence tomography angiography in retinal tumors: A narrative review

Intraocular tumors constitute a small subset of cases in ophthalmologic practice. Proper diagnosis of intraocular tumors is crucial because some pose threat to vision and life, while others may indicate underlying systemic disorders. Intraocular tumors comprise benign and malignant lesions affecting the retina, choroid, optic disc, iris, and ciliary body. Retinal tumors can be classified as vascular, neural, glial, and retinal pigment epithelial tumors. Optical coherence tomography angiography (OCTA) is a noninvasive imaging modality employed in diagnosis and management of retinal and choroidal vascular diseases, and has enhanced our knowledge in better understanding of the vascular physiology and pathology. Multiple case reports and small series evaluating the role of OCTA in retinal tumors are published in literature. OCTA helps in better understanding of the vascularity of intraocular tumors. In addition to this, OCTA has its role in clinical practice. It helps in identification of small retinal capillary hemangioblastoma (RCH), assessment of treatment response, and identification of tumor recurrence in RCH. It aids in identification of retinal astrocytic hamartoma missed on clinical examination and differentiating retinal astrocytic hamartoma and presumed solitary circumscribed retinal astrocytic proliferation. It helps in assessment of risk of tumor recurrence in retinoblastoma. It helps in differentiating tumors of retinal pigment epithelium (RPE) origin from pigmented tumors of the choroid. It also helps in detection of choroidal neovascular membrane in combined hamartoma of the retina and RPE.

Follow-up report of fundus findings of tuberous sclerosis-associated retinal astrocytoma of two siblings

A late adolescent with tuberous sclerosis (TS) presented with reduced vision in one eye to our tertiary care university hospital 4 years ago. Fundus examination revealed multiple retinal astrocytic hamartomas (RAHs) in both eyes. His younger sibling, who also had TS, was found to have RAH on retinal screening. The swept-source optical coherence tomography (SS-OCT) findings were typical of RAH. We further noted that some of the RAH lesions showed segmental whitening of the outer walls of the arterioles, which traversed through them. The segmental whitening may suggest the enveloping of normal retinal vessels by the tumour. En-face and B-scan SS-OCT angiography of patients with TS showed vascularity within the tumour. The vessels within the tumour appeared to be in continuity with the retinal vasculature. Both siblings were reviewed annually. At the end of 4 years, there was no change in visual acuity, tumour size, number, vascularity and behaviour.

A Review of Pediatric Ophthalmic Tumors

Tumors of the eye, orbit, and ocular adnexa can arise in the pediatric population. These entities can be both vision- and life-threatening and may be associated with systemic disease. Given their relative rarity, pediatricians must be aware of these conditions and understand what findings warrant immediate referral to an ophthalmologist for initiation of further testing. We aimed to review these conditions and highlight clinical features to promote awareness and expedite diagnosis. Tumors are subdivided into the following categories for review: anterior tumors of the eyelid and ocular surface, orbital tumors, and intraocular tumors.

Optical coherence tomography detection of retinal neural loss in patients with tuberous sclerosis

PURPOSE

Tuberous Sclerosis (TS) is a rare, multisystem genetic disease caused by mutations in the TSC1 and TSC2 genes, leading to abnormalities in cell differentiation and proliferation. This study aimed to evaluate the neural integrity of individuals with TS by using Optical Coherence Tomography (OCT) to examine the peripapillary retinal nerve fiber layer (RNFL) thickness and the macular thickness in patients with TS and to compare with healthy controls.

METHODS

Peripapillary and macular OCT scans (Optopol Revo NX SD OCT) were performed on 41 eyes from 22 TS patients, divided into two groups based on the presence of retinal hamartomas, and compared to 20 eyes from a control group. The average peripapillary RNFL thickness was measured for each quadrant. The macular total thickness and ganglion cell layer (GCL) + inner plexiform layer (IPL) thickness were measured based on the Early Treatment Diabetic Retinopathy Study (ETDRS) map. All measurements were then compared between the groups and controls.

RESULTS

The TS group showed significantly reduced RNFL thickness and macular thickness when compared to the control group. Specifically, patients with retinal hamartomas exhibited an even more pronounced thinning of both RNFL and macular thickness.

CONCLUSIONS

These findings suggest that TS patients undergo significant changes in retinal neurodevelopment and experience axonal loss. This finding may have significant prognostic utility regarding central nervous system degeneration in TS, particularly among patients with retinal hamartomas. OCT may serve as a valuable tool for assessing axonal structural abnormalities in TS patients.

TRIAL REGISTRATION NUMBER

Not applicable.

Retinal astrocytic hamartoma complicated by branch retinal vein occlusion in a patient with tuberous sclerosis complex

Purpose

To report a case with branch retinal vein occlusion secondary to a retinal astrocytic hamartoma in a patient with tuberous sclerosis complex.

Observations

A fourteen-year-old boy, a known case of tuberous sclerosis complex, with multiple bilateral retinal astrocytic hamartomas was followed by 6 months intervals. In his last follow-up, 6 months after initial presentation, the patient developed angiographic signs of branch retinal vein occlusion (BRVO) in the superotemporal arcade of the right eye distal to one of the retinal astrocytic hamartomas. He underwent targeted retinal laser photocoagulation. No secondary complication related to BRVO was observed during the next six-month follow-up.

Conclusion

And Importance: Although the co-occurrence of branch retinal vein occlusion and astrocytic hamartoma may represent an incidental finding, awareness of BRVO as a possible complication associated with retinal astrocytic hamartoma helps timely diagnosis and prompt treatment of this complication, improving the visual prognosis of these patients.

Retinal hamartomas at different stages in a patient with tuberous sclerosis: A OCT-SS description

Retinal astrocytic hamartoma (RAH) is a benign glial tumor that may be present in patients with tuberous sclerosis (TS), contributing to the diagnosis of this syndrome. While hamartomas identified through indirect ophthalmoscopy are often large enough to affect vessels and optic disc anatomy, RAH not detected in previous fundoscopies may become apparent in optical coherence tomography (OCT). The purpose of this report was to describe and characterize RAH with OCT with swept-source technology (OCT-SS), aiming to establish a more comprehensive classification for these hamartomas due to their diverse presentations. Fundus examination of a 11-year-old girl revealed retinal tumors in both eyes. OCT-SS confirmed the diagnosis of TS, revealing dome-shaped hyperreflective masses at different stages of evolution. Lesion 1: maximum thickness (MT) of 336 μm and ganglion cell layer disorganization. Lesion 2: MT of 438 μm and preserved outer plexiform layer. Lesion 3: posterior shadow, MT of 1478 μm and complete rupture of retinal anatomy. Lesion 4: MT of 342 μm and preserved retinal anatomy. OCT is a noninvasive method which assists the diagnosis of subclinical lesions and clinical characterization of TS patients.

Benign Lobular Inner Nuclear Layer Proliferations of the Retina Associated with Congenital Hypertrophy of the Retinal Pigment Epithelium

PURPOSE

To report the clinical and imaging findings of 4 patients with benign intraretinal tumors, 2 of which were associated with retinal pigment epithelium (RPE) hypertrophy. To our knowledge, this condition has not been described previously and should be distinguished from retinoblastoma and other malignant retinal neoplasms.

DESIGN

Retrospective case series.

PARTICIPANTS

Four patients from 3 institutions.

METHODS

Four patients with intraretinal tumors of the inner nuclear layer (INL) underwent a combination of ophthalmic examination, fundus photography, fluorescein angiography, OCT, OCT angiography, and whole exome sequencing.

MAIN OUTCOME MEASURES

Description of multimodal imaging findings and systemic findings from 4 patients with benign intraretinal tumors and whole exome studies from 3 patients.

RESULTS

Six eyes of 4 patients 5, 13, 32, and 27 years of age were found to have white intraretinal tumors that remained stable over the follow-up period (range, 9 months-4 years). The tumors were unilateral in 2 patients and bilateral in 2 patients. The tumors were white, centered on the posterior pole, and multifocal, with some consisting of multiple lobules with arching extensions that extended beyond the central tumor mass. OCT demonstrated these lesions to be centered within the INL at the border of the inner plexiform layer. In addition, 2 patients demonstrated congenital hypertrophy of the RPE (CHRPE) lesions. Three of 4 patients underwent whole exome sequencing of the blood that revealed no candidate variants that plausibly could account for the phenotype.

CONCLUSIONS

We characterize a novel benign tumor of the INL that, in 2 patients, was associated with separate CHRPE lesions. We propose the term benign lobular inner nuclear layer proliferation to describe these lesions.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found after the references.

Orbital Perivascular Epithelioid Cell Tumor in a Case of Tuberous Sclerosis

The aim of the study was to report a case of orbital perivascular epithelioid cell tumor (PEComa) in a known diagnosed patient of tuberous sclerosis and retinal astrocytic hamartoma. 43-year-old female presented with rapid progressive painful proptosis in the left eye, also reported new mass growing in her upper back. The patient past medical history is significant for left renal angiomyolipoma and multiple bilateral lung cysts of which she underwent right nephrectomy and lung biopsy, respectively. The lung biopsy turned diagnostic for lymphangiomyomatosis. On external examination, the left eye was grossly proptotic with hypoglobus. A typical butterfly distribution of sebaceous adenoma was noted across the patient cheeks and nose. Visual acuity in the right eye was 20/20 and the left eye, 20/25. Funduscopic examination identified type 1, 2, and 3 retinal astrocytic hamartomas. MRI brain and orbit was significant for a lesion arising from the lateral orbital wall with extensive bone destruction, displacing the left optic nerve medially. CT chest showed left extrathoracic mass had same radiological features as the orbital lesion; thus, an incisional biopsy performed on the former was diagnostic for PEComa with atypical features. This is the first observed case of PEComa in a known diagnosed patent with TS and retinal astrocytic hamartoma. The association of tuberous sclerosis complex and orbital PEComa is rarely and poorly reported in the literature compared to extraocular PEComa.

Multimodal imaging of a sporadic retinal astrocytic hamartoma simulating retinoblastoma in a newborn

Introduction

To report a sporadic astrocytic hamartoma simulating retinoblastoma in a newborn.

Methods

Clinical data was reviewed retrospectively.

Results

A 3-month-old baby with a history of perinatal asphyxia was referred to our ocular oncology clinic with suspected retinoblastoma in the left eye. Dilated fundoscopy revealed a solitary tumor covering the optic disc at the left eye. The whitish-yellow lesion was well-defined, opaque, and minimally calcified. High internal reflectivity and posterior shadowing due to the intralesional calcification, and intratumoral cystic spaces were observed in B-scan ultrasound imaging. Optical coherence tomography imaging showed an intraretinal tumor with cystic spaces and posterior shadowing. The tumor was diagnosed as an astrocytic hamartoma. The systemic evaluation was negative for phacomatoses. The lesion has been observed with multimodal imaging for six years without significant changes.

Conclusions

Retinal astrocytic hamartomas are benign tumors that arise within the retinal nerve fiber layer. Differential diagnosis constitutes high importance since they may be misdiagnosed as retinoblastoma, and therefore may be overtreated. Whereas retinoblastoma requires immediate treatment, retinal astrocytic hamartomas are commonly followed-up. Multimodal imaging with B-scan ultrasonography and optical coherence tomography are useful in distinguishing those two entities.

TWO-YEAR FOLLOW-UP OF A RETINAL ASTROCYTIC HAMARTOMA IMAGED BY OPTICAL COHERENCE TOMOGRAPHY ANGIOGRAPHY

PURPOSE

To report a case of retinal astrocytic hamartoma imaged by optical coherence tomography angiography (OCTA), followed for 2 years.

METHODS

Observational case report.

RESULTS

A 25-year-old woman was referred for an incidental retinal lesion in the left eye (LE). At baseline, the best-corrected visual acuity in the LE was 20/32, and fundus examination showed the presence of a round, pigmented lesion in juxtafoveal region, corresponding, on spectral domain OCT, to a hyperreflective lesion within nerve fiber layer. Optical coherence tomography angiography revealed the presence of a high-flow lesion in the superficial capillary plexus segmentation. The patient was followed up for 2 years: best-corrected visual acuity remained stable and multimodal imaging, including OCTA, confirmed the benign and stable nature of the lesion. At baseline, the total lesion area on OCTA (superficial capillary plexus) was 0.181 mm2, whereas vascular density was 52.080%; the total area was 0.204 mm2, and vascular density was 53.740% at 2-year follow-up.

CONCLUSION

Optical coherence tomography angiography is helpful not only for the diagnosis and follow-up of such rare tumors, but also it gives insights as to how these tumors develop and how they affect surrounding structures.

Familial exudative vitreoretinopathy associated with retinal astrocytic hamartoma

Purpose

To report the first case of retinal astrocytic hamartoma (RAH) arising in the setting of Familial Exudative Vitreoretinopathy (FEVR).

Observations

An otherwise healthy 3-month-old male was clinically diagnosed with Familial Exudative Vitreoretinopathy, with subsequent confirmation of a Frizzled-4 nonsense gene mutation. He was treated with multiple rounds of laser photocoagulation after demonstrated peripheral non-perfusion on fluorescein angiography. At 4 years of age, he was noted to have a solitary retinal astrocytic hamartoma in an area of anterior retinal traction which remains under observation.

Conclusions and Importance

This case describes the first reported instance of a retinal astrocytic hamartoma arising in the setting of FEVR. Multiple factors may have contributed to the formation of this benign tumor, including retinal dysgenesis, genetic background, or even laser photocoagulation. More case reports and/or molecular studies are required to further clarify the potential role of these insults in the pathogenesis of RAH.

Case Report: Multiple Retinal Astrocytic Hamartomas in Congenital Disorder of Glycosylation-Ia

Congenital disorder of glycosylation-Ia (CDG-Ia) is a rare autosomal recessive genetic disorder, characterized by systemic and ophthalmological abnormalities. Here, we report multiple retinal astrocytic hamartomas as a new retinal finding in an adolescent affected by congenital disorder of CDG-Ia. A 15-year-old boy affected by CDG-Ia underwent full ophthalmic examination, full field electroretinography (ERG) evaluation and retinal multimodal imaging, including: fundus photography, spectral domain optical coherence tomography (SD-OCT) and blue fundus autofluorescence (FAF). Blue FAF showed multiple papillary and iuxtapapillary bilateral hyper-FAF lesions, corresponding to hyperreflective thickening of the retinal nerve fiber layer, with internal optical empty spaces and posterior dense optical shadowing at SD-OCT. These imaging findings were consistent with retinal astrocytic hamartomas. Scotopic ERG response was significantly reduced in both eyes. Macular edema and absence of the retinal outer segments layer were also detectable. Retinal multi-modal imaging provides additional insights about retinal involvement of patients affected by CDG-Ia. In particular, this case shows the presence of multiple retinal astrocytic hamartomas.

Epiretinal membrane peeling as the treatment for macular edema associated with isolated retinal astrocytic hamartoma

Purpose:

Methods:

Results:

Conclusion:

Long-term follow-up of adult patient with neurofibromatosis type 1 with retinal astrocytic hamartoma using spectral-domain optical coherence tomography: a review of the literature and a report of a case

Background: Retinal astrocytic hamartoma (RAH) is a tumor that can be sporadic or in the context of tuberous sclerosis complex (TSC) and has been reported to be associated with neurofibromatosis type 1 (NF1) in a few cases.Patient and methods: A 65-year-old male patient with NF1 was referred for ophthalmological evaluation. Comprehensive examination, near-infrared reflectance (NIR), spectral-domain optical coherence tomography (SDOCT), fluorescein angiography (FFA), and indocyanine green angiography (ICGA) were carried out. The follow-up of the patient was at 4 and 7 years.Results: Best-corrected visual acuity (BCVA) was 20/20 in both eyes. Anterior segment examination revealed bilateral Lisch nodules. Fundus examination was unremarkable but at NIR and SDOCT the patient presented choroidal hamartoma, microvascular retinal alterations, and enlarged choroidal vessels in both eyes. NIR also revealed an unusual area of peripapillary hyporeflectivity in the right eye. On SDOCT, this corresponded to an elevated peripapillary mass characterized by intralesional optically empty cavities in the retinal nerve fiber layer (RNFL) and ganglion cell layer-inner plexiform layer (GCL-IPL), diagnosed as a RAH. Four years later, BCVA was 20/25 with a retinal schisis departing from the lesion to the macula. At 7 years, BCVA was stable at 20/25, the lesion was smaller, and there was a slight reduction of the schisis.Conclusion: RAH is a rare finding in NF1 and the translucent type has not been previously reported. RAH in NF1 has a peripapillary location and demonstrates clinically unpredictable behavior; thus, close monitoring with multimodal imaging is advisable.

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.

Retinal manifestations of the neurocutaneous disorders

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

SUMMARY

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

Presumed retinal pericapillary astrocytic hamartoma: multimodal imaging findings of a novel hamartomatous lesion

PURPOSE

To describe the multimodal imaging findings of retinal lesions that clinically resemble retinal astrocytic hamartomas (RAHs), but also have unique characteristics that we believe represent a novel variant.

METHODS

Observational study. Five eyes in five patients with solitary retinal lesion evaluated at the retina division of three institutions. We describe the multimodal imaging findings including fundus photography, fundus autofluorescence, fluorescein angiography, spectral-domain optical coherence tomography (OCT), swept-source OCT, swept-source OCT angiography and ultrasonography.

RESULTS

The retinal lesions described shared similar appearance to RAHs but demonstrated unique features such as glistening granular appearance on fundus photographs with perivascular hyperreflectivity with OCT and OCT angiography.

CONCLUSION

The lesions described herein appear to have unique characteristics that warrant a designation as a novel RAH variant. The name presumed retinal pericapillary astrocytic hamartoma is suggested.

Swept-source optical coherence tomography angiography findings in choroidal and retinal tumors

OBJECTIVES

To report the swept-source optical coherence tomography angiography (SS-OCTA) findings in choroidal and retinal tumors.

METHODS

A retrospective noncomparative interventional case series of 60 eyes having various choroidal and retinal tumors imaged with SS-OCTA (Topcon DR1 Triton Plus, Tokyo, Japan) between September 2018 and February 2020 was conducted. Inclusion criteria were tumor thickness <4 mm, tumor base diameter <10 mm, and tumor location at the posterior pole.

RESULTS

Choroidal nevi usually demonstrated well-defined borders, hyperreflective internal structure, and no outer retinal involvement on SS-OCTA. Choroidal melanoma, in contrast to nevi, usually had ill-defined borders (p = 0.018), mixed hyperreflective-hyporeflective or hyperreflective internal structure (p = 0.014), and demonstrated outer retinal involvement (p < 0.001). Circumscribed choroidal hemangioma usually presented with well-defined borders, a hyperreflective internal tumor structure with multiple dilated interconnected tumor vessels intermixed with signal void areas representing connective tissue. Optic disc melanocytomas showed a hyporeflective plexus related to blocking of signal by the pigment and an intact radial peripapillary capillary network. There was flow on the surface and slightly deeper within the lesion on B-scan angiography overlay. Retinal astrocytic hamartomas had well-defined borders and a hyperreflective vascular plexus in the superficial and deep retina. Outer retina and choriocapillaris showed hyporeflective change due to shadowing/masking from calcium or high blood flow in the lesion.

CONCLUSIONS

Each of the different retinal and choroidal tumors studied in this series presented with different SS-OCTA features to aid in the differential diagnosis of these conditions. Good quality images are obtained in patients with good fixation and tumors <3 mm in thickness located at the posterior pole.

[Tumor-like diseases and retinal hamartomas in ophthalmological practice]

The article provides a detailed review of the ophthalmoscopic picture, optical coherence tomography (OCT) of the retina and fundus autofluorescence in patients with such rare pathological processes in the fundus as torpedo maculopathy, retinal myelin fibers, retinal astrocytic hamartoma and cavernous hematoma.

Optical coherence tomography in pediatric patients: a clinical review

Optical coherence tomography has improved the ophthalmic clinical examination due to its ability to more accurately characterize pathology of the eye. Optical coherence tomography is now an integral imaging modality for many adult diseases of the retina and is a ubiquitous part of a retinal practice. However, although its use in adults is well recognized, the adoption of optical coherence tomography in pediatric patients may be undervalued as macular diseases in children are relatively uncommon. Recent technological advancements have made optical coherence tomography scans quicker and more precise, generating normative data and leading to more widespread use in children. In this review article, we discuss how pediatric optical coherence tomography data can be used to understand normal development, as well as diagnose and monitor retinal disease. In particular, we highlight clinical optical coherence tomography findings of several pediatric retinal conditions, including retinopathy of prematurity, congenital infections, retinal dystrophies, and phakomatoses such as neurofibromatosis.

Clinical features and optical coherence tomography findings of retinal astrocytic hamartomas in Chinese patients with tuberous sclerosis complex

PURPOSE

To investigate the clinical features and spectral-domain optical coherence tomography (SD-OCT) findings of retinal astrocytic hamartoma (RAH) in Chinese patients with tuberous sclerosis complex (TSC).

METHODS

The medical records of 91 consecutive patients with established TSC diagnosis were retrospectively reviewed. Fundus findings regarding RAH documented by fundus photography and SD-OCT at presentation were collected and analyzed.

RESULTS

RAHs were seen in 69 of the 91 patients (75.8%); 50.7% of these patients showed bilateral retinal involvement. Type 1 RAH was found the most common type with a prevalence of 94.2%, while type 2 and type 3 RAH with 7.2% and 18.8% respectively. A significant correlation between age and RAH types was shown by Fisher's exact test (p < 0.001). By SD-OCT, non-calcified RAHs featured in hyperreflective thickening of the retinal nerve fiber layer with some degree of retinal disorganization, while multinodular calcified RAHs characterized with moth-eaten appearances representing intraretinal calcification with posterior dense optical shadowing.

CONCLUSION

A higher prevalence of TSC-associated RAH but an unexpected lower prevalence of calcified RAHs was shown in Chinese compared with that of Caucasians. SD-OCT can be used to facilitate the detection and follow-up of RAHs.

INVISIBLE, HONEYCOMB-LIKE, CAVITARY RETINAL ASTROCYTIC HAMARTOMA

PURPOSE

To report a patient with clinically invisible retinal astrocytic hamartomas (RAHs) detected on optical coherence tomography (OCT) and studied with OCT angiography (OCTA).

METHOD

Case report.

RESULTS

An 11-year-old healthy girl was evaluated for reduced visual acuity in the right eye. On examination, best-corrected visual acuity was 20/50 in the right eye and 20/20 in the left eye. Fundus examination revealed blunted foveal reflex in the right eye and normal findings in the left eye. Optical coherence tomography disclosed an abruptly elevated, honeycomb-like macular mass with thin filamentous walls in the right eye, limited to the nerve fiber layer and measuring 756 μm in thickness. The numerous intralesional cavities (optically empty spaces) displayed no calcification. These findings were consistent with Type IV RAH. Optical coherence tomography of the left eye revealed intact foveola and focal nerve fiber layer thickening inferiorly without cavity, measuring 136 μm in thickness, consistent with Type I RAH. En face OCTA detected microvascular flow within the walls of the cavitary RAH in the right eye. Bilateral RAH in a child with no systemic evidence of tuberous sclerosis syndrome was established.

CONCLUSION

Multimodal imaging is important in revealing causes of visual loss and in the detection of subclinical fundus tumors. In this case, clinically invisible RAHs were detected only by OCT and surrounding vascular flow by OCTA.

Linear and planar reflection artifacts on swept-source and spectral-domain optical coherence tomography due to hyperreflective crystalline deposits

PURPOSE

To describe novel spectral-domain (SD) and swept-source (SS) optical coherence tomography (OCT) linear and planar reflection artifacts produced by hyperreflective crystalline deposits (HCD).

METHODS

Imaging from 10 eyes with HCD producing linear and planar artifacts on OCT was retrospectively analyzed. All eyes had SD-OCT (Spectralis HRA + OCT, Heidelberg Engineering, Germany) and SS-OCT angiography (PLEX Elite 9000, Carl Zeiss Meditec, Inc., Dublin, CA) acquired on the same day. The horizontal extent of planar artifacts and the corresponding HCD on B-scans was measured using a digital caliper. Artifact features from HCD in eyes with non-neovascular age-related macular degeneration (AMD) were analyzed and compared to those seen in two eyes with the "onion sign," an OCT signature previously shown to represent cholesterol crystals (CC) in the sub-retinal pigment epithelium-basal laminar space of eyes with neovascular AMD. A third eye with the "onion sign" was imaged with dense B-scan (DB)-OCTA.

RESULTS

Ten eyes of ten patients (77.4 ± 8.7 years) with HCD were analyzed. On SS-OCTA, HCD produced linear artifacts of high signal intensity passing through the HCD and spanning the entire scan depth. On SD-OCT, HCD produced planar artifacts located anterior to both the retina and a hyporeflective space representing normal vitreous signal. The horizontal extent of the artifact did not differ significantly from the corresponding HCD on OCT B-scans (P = 0.62). The OCT artifacts produced by the "onion sign" appeared similar to those of HCD. The additional eye with neovascular AMD imaged with DB-OCTA was characterized by a single, vertical, linear false-flow signal crossing retinal layers.

CONCLUSIONS

To the authors' knowledge, this is the first description of SD- and SS-OCT/OCTA artifacts corresponding to both HCD and the "onion sign." These artifacts are likely due to highly reflective CC previously shown on histology to correspond to both of these OCT signatures.

Optical Coherence Tomography of Choroid in Common Neurological Diseases

The choroid is involved directly and indirectly in many pathological conditions such as age-related macular degeneration, myopia-related chorioretinal atrophy and central serous chorioretinopathy. Optical coherence tomography (OCT) has gradually become a fundamental part of modern resources in the hands of ophthalmologists. The enhanced depth imaging technique and swept-source OCT make a great contribution to conventional in vivo choroid assessment. This review focuses on the most common neurological conditions in which choroid assessment by OCT may provide help in early diagnosis and be used as an interdisciplinary follow-up tool. In order to avoid evaluation biases and misdiagnosis, the main and most common physiological and para-physiological conditions in which the choroid may show alterations are also reviewed.

Vitreous haemorrhage a rare manifestation of retinal astrocytic hamartoma: a paediatric case report

INTRODUCTION

Retinal astrocytic hamartoma is generally an asymptomatic benign tumour that may or may not be associated with the tuberous sclerosis complex. Haemorrhage is a rare presentation.

CASE REPORT

The case concerns a 12-year-old patient with "a black spot" vision in the upper temporal hemifield of the right eye, who referred a similar episode 2 years ago. The anterior pole was normal in the slit lamp. A mass of translucent white-yellow peri-papillary appearance and vitreous peri-papillary haemorrhage was observed in funduscopy. The autofluorescence, fluorescence angiography, and optical coherence tomography characteristics were all compatible with retinal astrocytic hamartoma. Complementary studies (serology and X-rays) and the complete clinical examination rule out associated systemic involvement. The patient was followed-up closely until the vitreous haemorrhage was reabsorbed.

CONCLUSION

Vitreous haemorrhage is a rare complication of Retinal astrocytic hamartoma and funduscopic exploration is difficult. Systemic involvement should be ruled out.

Presumed solitary circumscribed retinal astrocytic proliferation: a lesion that can regress

A 56-year-old woman had an yellow-white retinal lesion superior to the optic disc. Optical coherence tomography demonstrated the mass with a snowball configuration and smooth surface. Autofluorescence disclosed revealed moderate hypoautofluorescence. Ultrasonography showed no calcification. Visual field examination showed an enlargement of the blind spot corresponding to the predominantly superotemporal juxtapapillary extension of the lesion. Eight months later, the lesion spontaneously resolved. Presumed solitary circumscribed retinal astrocytic proliferation (PSCRAP) is a benign stable retinal tumor, but PSCRAP has been reported to resolve spontaneously here. It differs from other white or yellow-white lesions of the retina in important ways that enable the ophthalmologist to reassure the patient as to its benign prognosis.

Retinal astrocytic hamartoma in tuberous sclerosis complex in an elderly person: a case report

Background

Spectral domain optical coherence tomography (SD-OCT) is proposed as a way of predicting the development and likelihood of retinal astrocytic hamartoma (RAH) in tuberous sclerosis complex (TSC) in elderly patients.

Case presentation

This report describes a case of RAH in TSC in an elderly patient. The patient was a 62-year-old woman and experienced pain in the lower left abdomen for two years. Bilateral renal angiomyolipoma, multiple hepatic angiomyolipoma and multiple pulmonary nodules were demonstrated using computed tomography (CT). Brain CT showed bilateral multiple calcification near by the cella lateralis. A clinical diagnosis of TSC was made. Visual acuity (decimal) in the right and left eye was determined to be 0.6 and 0.8, respectively. SD-OCT revealed a retinal tumour in the inner layer of the retina in the right fundus and a pre-retinal membrane which may have evolved later.

Conclusions

A routine ophthalmic examination is advised for patients suspected of having TSC to prevent this condition from being overlooked. In addition, an OCT examination can be used to predict the development and likelihood of RAH.

Calcified nodules in retinal drusen are associated with disease progression in age-related macular degeneration

Drusen are lipid-, mineral-, and protein-containing extracellular deposits that accumulate between the basal lamina of the retinal pigment epithelium (RPE) and Bruch's membrane (BrM) of the human eye. They are a defining feature of age-related macular degeneration (AMD), a common sight-threatening disease of older adults. The appearance of heterogeneous internal reflectivity within drusen (HIRD) on optical coherence tomography (OCT) images has been suggested to indicate an increased risk of progression to advanced AMD. Here, in a cohort of patients with AMD and drusen, we show that HIRD indicated an increased risk of developing advanced AMD within 1 year. Using multimodal imaging in an independent cohort, we demonstrate that progression to AMD was associated with increasing degeneration of the RPE overlying HIRD. Morphological analysis of clinically imaged cadaveric human eye samples revealed that HIRD was formed by multilobular nodules. Nanoanalytical methods showed that nodules were composed of hydroxyapatite and that they differed from spherules and BrM plaques, other refractile features also found in the retinas of patients with AMD. These findings suggest that hydroxyapatite nodules may be indicators of progression to advanced AMD and that using multimodal clinical imaging to determine the composition of macular calcifications may help to direct therapeutic strategies and outcome measures in AMD.

Optic coherence tomography appearances of retinal astrocytic hamartoma and systemic features in tuberous sclerosis of Japanese patients

Purpose:

To describe the optical coherence tomography findings of retinal astrocytic hamartoma of tuberous sclerosis and to confirm the association between the type of retinal astrocytic hamartoma and systemic manifestations in Japanese patients.

Study Design:

A retrospective observational case series.

Methods:

The medical records of 35 patients with tuberous sclerosis who underwent ophthalmological examination were reviewed. The retinal astrocytic hamartomas were classified into four types based on the optical coherence tomography findings, and their association with systemic disease was evaluated.

Results:

A total of 40 retinal astrocytic hamartomas in 13 eyes of eight patients aged 4–28 years were identified. Optical coherence tomography images were obtained for 23 lesions in 10 eyes of seven patients. Retinal astrocytic hamartomas were seen as protruding lesions of varying heights (maximum thickness, range between 221 to 1043 μm). Of the 23, 15 lesions showed homogeneous reflectivity; in six lesions, hyper-reflective spots that presumably represented intratumoral calcification were noted. Vitreous changes were noted in 13 lesions; vitreous seeding by retinal astrocytic hamartoma was observed in seven eyes. There were no significant differences in the rates of each systemic feature among the optical coherence tomography types.

Conclusion:

Retinal astrocytic hamartomas were classified into four types according to the previous reports; however, this classification may be worthless because the extent of protrusion did not correspond to the intratumoral characteristics, and the involved depth of the retina was not same even in the same type. An association between the type of retinal astrocytic hamartoma and systemic manifestations was not confirmed in this small case series. We considered that the classification of retinal astrocytic hamartoma and its association with systemic manifestations need further study.

Spare some internal limiting membrane for later: free ILM patch and neurosensory retina graft

PURPOSE

Editorial to De Giacinto et al case report on free autologous neurosensory retina patch.

METHODS

Literature review and experts' opinion RESULTS: In the present issue, De Giacinto et al describe a free autologous neurosensory retina patch to close a chronic macular hole. This new technique was made necessary by an extended internal limiting membrane peeling during the first surgery, that prevented grafting a patch of internal limiting membrane when the hole did not close. We hereby review pros and cons of patching a chronic macular hole with an internal limiting membrane patch, as well as the importance of not over-enlarging a peeling.

DISCUSSION

Internal limiting membrane patch can be considered in chronic macular holes. It may not be an option in cases of over-enlargement of a previous peel; free autologous neurosensory retina patch may be a valid alternative in such cases.

NEWLY DIAGNOSED ASYMPTOMATIC RETINAL ASTROCYTIC HAMARTOMA IN AN OLDER ADULT

BACKGROUND

To report a coincidentally discovered retinal astrocytic hamartoma in an asymptomatic older woman with no history of tuberous sclerosis or neurofibromatosis.

METHODS

A 63-year-old Turkish woman underwent routine ophthalmic examination.

RESULTS

Visual acuity was 20/25 in each eye. On fundus examination, the right eye showed a flat yellow-white superficial retinal lesion in the inferotemporal macula and measuring 1 mm in diameter. The lesion was unmeasurable using B-mode ultrasonography. Spectral domain optical coherence tomography revealed the mass with thickening in the retinal nerve fiber layer, with minor disorganization of the underlying retina and no retinal or vitreoretinal traction. Fluorescein angiography disclosed the mass as early isofluorescence with late mild hyperfluorescence, without leakage. Findings in the left eye were normal. Based on the clinical and imaging results, a diagnosis of noncalcified small retinal astrocytic hamartoma was rendered. The lesion remained unchanged at 1-year follow-up.

CONCLUSION

Small coincidentally discovered retinal astrocytic hamartomas in older patients can be difficult to diagnose and possibly cause diagnostic confusion with other conditions including myelinated nerve fiber and cotton wool spot. Retinal astrocytic hamartoma is characterized by thickening of the retinal nerve fiber layer and mild compression and disorganization of the underlying retinal layers on spectral domain optical coherence tomography.

OPTICAL COHERENCE TOMOGRAPHY AND INFRARED IMAGES OF ASTROCYTIC HAMARTOMAS NOT REVEALED BY FUNDUSCOPY IN TUBEROUS SCLEROSIS COMPLEX

PURPOSE

To detect, describe, and classify the morphologic characteristics of astrocytic hamartomas in tuberous sclerosis complex, using both spectral-domain optical coherence tomography (OCT) and infrared images.

METHODS

Ten subjects (20 eyes) with tuberous sclerosis complex underwent a complete ophthalmologic examination and multimodality imaging with spectral-domain OCT and infrared images. The imaging protocol included a 30°scan angle of the posterior pole and of the four quadrants. Line scans, detail, raster, and posterior pole patterns were used. The identified astrocytic hamartomas were described and characterized qualitatively and quantitatively.

RESULTS

Forty-four hamartomas were detected in 8 patients. In five cases, lesions were bilateral. Thirty of these hamartomas had not been revealed by previous ophthalmoscopy. Through multimodality imaging, it was possible to define multiple lesions with characteristic optical reflective qualities. All the 44 hamartomas were measured and morphologically characterized in terms of the type of tumor, retinal and/or vitreous involvement, calcifications, and posterior optical shadowing.

CONCLUSION

The combined imaging with spectral-domain OCT and infrared images improves the detection of hamartomas if compared with the spectral-domain OCT technique alone. Moreover, a new subtype of hamartoma is proposed to complete a previous classification based on OCT.

Association of Myelinated Retinal Nerve Fibers With Acquired Mulberry Retinal Astrocytoma: Coincidental or Relational?

Retinal astrocytoma is an important ocular finding for diagnosis of tuberous sclerosis complex and is also an association of neurofibromatosis. The authors present findings of a case of acquired astrocytoma associated with myelinated retinal nerve fibers. The authors also discuss the images and possible cause-effect relationship between them. [Ophthalmic Surg Lasers Imaging Retina. 2017;48:441-442.].

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.

Association of bilateral, multiple presumed retinal astrocytic proliferations with combined hamartoma of retina and retinal pigment epithelium in a 9-year-old male child with neurofibromatosis type 2

Neurofibromatosis type 2 (NF-2) is characterized by multifocal proliferation of neural crest-derived cells. The characteristics finding of NF-2 is bilateral vestibular schwannomas. Combined hamartoma of retina and retinal epithelium (CHRRPE) is another associated finding. A 9 year-old-male child presented with left eye decreased vision for 3 months. Visual acuity was 0.0 and 0.8 LogMAR in the right and left eye, respectively. Left fundus showed an elevated, pigmented lesion with surface wrinkling and vascular tortuosity suggestive of CHRRPE with multiple presumed retinal astrocytic proliferations in mid-periphery. He had multiple café-au-lait spots. Optical coherence tomography confirmed clinical findings. Magnetic resonance imaging brain showed bilateral acoustic neuroma. Recognition of this rare finding as presenting feature of NF-2 can lead to earlier diagnosis which is vital to appropriate surveillance and possible surgical intervention. It is recommended that children with CHRRPE be screened for NF-2.

EN FACE OPTICAL COHERENCE TOMOGRAPHY (OCT) AND OCT ANGIOGRAPHY FINDINGS IN RETINAL ASTROCYTIC HAMARTOMAS

PURPOSE

To report spectral-domain optical coherence tomography, en face optical coherence tomography (OCT), and optical coherence tomography angiography findings in retinal astrocytic hamartomas.

METHODS

Four cases of retinal astrocytic hamartomas, with small white or yellowish typical retinal mass, were imaged with fundus photography, intravenous fluorescein angiography, fundus autofluorescence, spectral-domain OCT, en face OCT, and OCT angiography.

RESULTS

The tumor was solitary in all cases and involved the posterior pole. It was idiopathic in three cases and was related to tuberous sclerosis complex in one case. The OCT findings included intralesional lucencies in two cases with no exudation. The tumor was within the retinal nerve fiber layer or deeper, usually overlying the inner plexiform layer providing a protusion in the vitreous cavity. Vitreous changes were present in all cases, corresponding to thickening and adhesion of the vitreous facing the lesion (two cases), apparent interdigitation with vitreous (one case), and marked condensation of the vitreous with interdigitations (one case). En face OCT imaging at the level of the retinal pigment epithelial zone showed a hyporeflective, round, well-delineated mass. A peripheral poorly defined hyperreflectivity with a central hyporeflectivity was observed at the level of mid-retina, likely because of shadowing effect. The OCT-A reveals a dense vascular network within the tumor.

CONCLUSION

Retinal astrocytic hamartomas may be well characterized by non-invasive imaging using spectral-domain OCT, en face OCT, and OCT angiography. The OCT angiography seemed to show tumor vascularity, which may represent dilated disorganized and anastomotic superficial and deep plexus capillaries. The tumor is often unique, peripapillary, small in diameter, and dome-shaped on spectral-domain OCT protruding into the vitreous cavity, responsible for vitreous changes facing the lesion.