INTRAVITREAL BEVACIZUMAB IN THE MANAGEMENT OF SUBRETINAL FLUID ASSOCIATED WITH CHOROIDAL OSTEOMA

Central serous chorioretinopathy: An evidence-based treatment guideline

Central serous chorioretinopathy (CSC) is a relatively common disease that causes vision loss due to macular subretinal fluid leakage and it is often associated with reduced vision-related quality of life. In CSC, the leakage of subretinal fluid through defects in the retinal pigment epithelial layer's outer blood-retina barrier appears to occur secondary to choroidal abnormalities and dysfunction. The treatment of CSC is currently the subject of controversy, although recent data obtained from several large randomized controlled trials provide a wealth of new information that can be used to establish a treatment algorithm. Here, we provide a comprehensive overview of our current understanding regarding the pathogenesis of CSC, current therapeutic strategies, and an evidence-based treatment guideline for CSC. In acute CSC, treatment can often be deferred for up to 3-4 months after diagnosis; however, early treatment with either half-dose or half-fluence photodynamic therapy (PDT) with the photosensitive dye verteporfin may be beneficial in selected cases. In chronic CSC, half-dose or half-fluence PDT, which targets the abnormal choroid, should be considered the preferred treatment. If PDT is unavailable, chronic CSC with focal, non-central leakage on angiography may be treated using conventional laser photocoagulation. CSC with concurrent macular neovascularization should be treated with half-dose/half-fluence PDT and/or intravitreal injections of an anti-vascular endothelial growth factor compound. Given the current shortage of verteporfin and the paucity of evidence supporting the efficacy of other treatment options, future studies-ideally, well-designed randomized controlled trials-are needed in order to evaluate new treatment options for CSC.

[Long-term outcome of macular neovascularization secondary to choroidal osteoma with and without intravitreal anti-VEGF(vascular endothelial growth factor)- treatment]

BACKGROUND

Choroidal osteoma (CO) is a benign ossifying ocular tumor, which is unilateral in most cases. The CO may cause severe visual impairment, especially in the case of a secondary macular neovascularization (MNV).

OBJECTIVE

Based on a case series of patients with MNV secondary to CO, the variability of the clinical course with and without intravitreal anti-vascular endothelial growth factor (VEGF) treatment is presented.

METHODS

All patients diagnosed with secondary MNV due to CO between 2007 and 2023 were retrospectively assessed with respect to the clinical course.

RESULTS

In this study 7 eyes of 5 patients (4 women, 1 man) were diagnosed with secondary MNV due to CO. Intravitreal anti-VEGF treatment was carried out in 2 patients with unilateral MNV and 1 patient was treated in both eyes for bilateral MNV. In another case with bilateral MNV, only 1 eye was treated because of fibrosis in the other eye. A further case with unilateral CO and MNV scars at the initial diagnosis was left untreated. Overall, in 3 out of 5 eyes treated with intravitreal VEGF inhibition stabilization or improvement of visual acuity could be achieved.

CONCLUSION

In our case series intravitreal anti-VEGF treatment attained a functional stabilization or improvement in 3 out of 5 treated eyes. In one case of CO-associated MNV fibrosis rapidly developed without treatment. Therefore, the clarification for patients with CO about the lifelong risk for development of a secondary MNV is essential in individual cases for early treatment. As no standardized treatment scheme for intravitreal VEGF antibodies for CO-related MNV exists, the treatment is planned on an individual basis.

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.

Predicting Visual Outcomes in Choroidal Osteoma Treated with Anti-vascular Endothelial Growth Factor

PURPOSE

To determine potential factors associated with the long-term visual prognoses in patients with choroidal osteoma undergoing anti-vascular endothelial growth factor (VEGF) treatment.

DESIGN

Retrospective case series.

METHODS

Patients diagnosed at tertiary high-volume hospitals between January 2000 and December 2020 were evaluated. The primary outcome measure was visual acuity at 5-year follow-up. The secondary outcome measures included factors associated with favorable vision, defined as loss of <1 line and >20/200 vision.

RESULTS

Of 38 eyes from 36 patients (22 female, 61%; mean age 38 years) with choroidal osteoma, 23 eyes (61%) received anti-VEGF treatment (bevacizumab 1.25mg/0.05 cc, monthly or treat-and-extend) and 65% completed the 5 years of follow-up. All treated eyes had associated chorioretinal comorbidities (subretinal fluid 91%; choroidal neovascularization 74%; subretinal hemorrhage 30%). Although there was significant vision loss by 5 years (P = .002), 12 eyes (44%) had favorable outcomes. Only tumor thickness was significantly associated with unfavorable visual outcomes (OR 917.1, 95% CI 1.0-5687.7; P = .049). The optimal cut-off point predictive of visual outcomes was 1.4 mm, and tumor thickness ≥ 1.4 mm was associated with unfavorable vision (OR 27.0, 95% CI 2.0-368.4; P = .013).

CONCLUSIONS

Among patients with choroidal osteoma undergoing anti-VEGF therapy, a particular patient subset presented with divergent outcomes with very poor vision. Tumor thickness appeared to be the differentiating factor and is thus a potential prognostic indicator for long-term visual prognoses.

Serous business: Delineating the broad spectrum of diseases with subretinal fluid in the macula

A wide range of ocular diseases can present with serous subretinal fluid in the macula and therefore clinically mimic central serous chorioretinopathy (CSC). In this manuscript, we categorise the diseases and conditions that are part of the differential diagnosis into 12 main pathogenic subgroups: neovascular diseases, vitelliform lesions, inflammatory diseases, ocular tumours, haematological malignancies, paraneoplastic syndromes, genetic diseases, ocular developmental anomalies, medication-related conditions and toxicity-related diseases, rhegmatogenous retinal detachment and tractional retinal detachment, retinal vascular diseases, and miscellaneous diseases. In addition, we describe 2 new clinical pictures associated with macular subretinal fluid accumulation, namely serous maculopathy with absence of retinal pigment epithelium (SMARPE) and serous maculopathy due to aspecific choroidopathy (SMACH). Differentiating between these various diseases and CSC can be challenging, and obtaining the correct diagnosis can have immediate therapeutic and prognostic consequences. Here, we describe the key differential diagnostic features of each disease within this clinical spectrum, including representative case examples. Moreover, we discuss the pathogenesis of each disease in order to facilitate the differentiation from typical CSC.

Choroidal osteoma: the varied response of subretinal fluid to anti-VEGF agents

The present case shows a remarkable long-term response of the choroidal neovascular membrane and serous retinal detachment associated with choroidal osteoma to two injections of ranibizumab which is an anti-vascular endothelial growth factor (anti-VEGF) agent.

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.

Treatment response to intravitreal bevacizumab in small pigmented choroidal lesions with subretinal fluid

Background

To describe the effects of intravitreal bevacizumab injection (IVB) and/or transpupillary thermotherapy (TTT) in the treatment of small pigmented choroidal lesions with subfoveal fluid (SFF), and to investigate prognostic value of the therapeutic response in future tumor growth.

Methods

Retrospective chart review of 19 patients, who were diagnosed with choroidal neovascularization (CNV)-free small pigmented choroidal lesions and treated with IVB and/or TTT, was performed.

Results

Complete resolution of SFF was achieved in two eyes (2/14; 14.3%) after IVB, and in three eyes (3/4; 75%) after TTT. Best corrected visual acuity was improved in two eyes (2/9; 22%) after IVB, and in three eyes (3/4; 75%) after TTT. Among five patients who underwent TTT after IVB, four patients (4/5; 80%) demonstrated additional advantage. All IVBs could not reduce tumor sizes. Rather, tumor growth was detected in seven out of 14 eyes (7/14; 50%) that underwent IVB. None of the patients who underwent TTT showed tumor growth. The lack of treatment response to IVB was suggestive of malignancy, as most small pigmented lesions that had no response to IVB showed tumor growth (86%, p = 0.010).

Conclusion

IVB was not effective in reducing tumor size and subfoveal fluid in small pigmented choroidal lesions. Therapeutic response to IVB can be used as an indicator between melanoma and nevus in small pigmented choroidal lesion.

Nonconforming Deep Focal Choroidal Excavation in a Patient With Choroidal Osteoma: A Diagnostic Dilemma

Evolution of an osteoma may result in neurosensory detachment, deossification, and choroidal neovascularization (CNV). The authors report a rare case of choroidal osteoma with CNV associated with a deep non-conforming focal choroidal excavation. [Ophthalmic Surg Lasers Imaging Retina. 2017;48:944-947.].

Anatomical and Gene Expression Changes in the Retinal Pigmented Epithelium Atrophy 1 (rpea1) Mouse: A Potential Model of Serous Retinal Detachment

Purpose

The purpose of this study was to examine the rpea1 mouse whose retina spontaneously detaches from the underlying RPE as a potential model for studying the cellular effects of serous retinal detachment (SRD).

Methods

Optical coherence tomography (OCT) was performed immediately prior to euthanasia; retinal tissue was subsequently prepared for Western blotting, microarray analysis, immunocytochemistry, and light and electron microscopy (LM, EM).

Results

By postnatal day (P) 30, OCT, LM, and EM revealed the presence of small shallow detachments that increased in number and size over time. By P60 in regions of detachment, there was a dramatic loss of PNA binding around cones in the interphotoreceptor matrix and a concomitant increase in labeling of the outer nuclear layer and rod synaptic terminals. Retinal pigment epithelium wholemounts revealed a patchy loss in immunolabeling for both ezrin and aquaporin 1. Anti-ezrin labeling was lost from small regions of the RPE apical surface underlying detachments at P30. Labeling for tight-junction proteins provided a regular array of profiles outlining the periphery of RPE cells in wild-type tissue, however, this pattern was disrupted in the mutant as early as P30. Microarray analysis revealed a broad range of changes in genes involved in metabolism, signaling, cell polarity, and tight-junction organization.

Conclusions

These data indicate changes in this mutant mouse that may provide clues to the underlying mechanisms of SRD in humans. Importantly, these changes include the production of multiple spontaneous detachments without the presence of a retinal tear or significant degeneration of outer segments, changes in the expression of proteins involved in adhesion and fluid transport, and a disrupted organization of RPE tight junctions that may contribute to the formation of focal detachments.

Assessment of choroidal osteoma complicating choroidal neovascularization by optical coherence tomography angiography

Purpose

Choroidal osteoma (CO) frequently leads to progressive visual loss due to complications of secondary choroidal neovascularization (CNV).We report herein the function of optical coherence tomography angiography (OCTA) in observation of CO complicating CNV.

Methods

A 25-year-old female presented to our hospital with chief complaint of sudden unilateral visual acuity decrease for one week, with metamorphopsia in the left eye. Her best corrected visual acuity was 0.12 in the left eye. Then complete ophthalmological examinations including fundus photography, B-scan ultrasound, fundus fluorescent angiography, and spectral-domain optical coherence tomography (SD-OCT) were performed. She was diagnosed as CO on the basis of these results. But the diagnosis could not explain the sudden visual loss and submacular hyperreflective lesion by SD-OCT. Furthermore, she underwent OCTA and indocyanine green angiography.

Results

A diagnosis of classic juxtafoveal CNV secondary to CO was made eventually. Then she was treated with an intravitreous injection of ranibizumab twice. The visual acuity got better and better during the treatment, and the efficacy was stable, giving rise to both subjective and anatomic improvement.

Conclusions

Optical coherence tomography angiography has the advantage of varying the segmentation and scrolling through the different retinal layers, and layer-specific observation of blood flow in each layer. In addition, OCTA can measure the vessel area change of CNV and provide a better appreciation of CNV, observing the efficacy more elaboratively and quantizedly. OCTA makes promising noninvasive identification of the CO-related CNV.

Choroidal osteoma

This study describes the clinical features, methods of diagnosis, and treatment of a rare intraocular tumor, choroidal osteoma, based on our observation of three patients and a literature review.

Intravitreal Bevacizumab for Management of Choroidal Osteoma without Choroidal Neovascularization

To report a patient with juxtapapillary choroidal osteoma (CO) with serous retinal detachment (SRD) not associated with choroidal neovascularization (CNV) who was successfully treated with a single intravitreal injection of bevacizumab. A 20-year-old woman presented with decreased vision in her right eye. Ultrasonography, fundus autofluorescence, fluorescein angiography (FA) and optical coherence tomography (OCT) were performed. She was diagnosed with juxtapapillary CO with SRD in the absence of CNV. The treatment involved a single intravitreal injection of bevacizumab. Visual acuity (VA) was 20/100 pre-injection which was dramatically improved to 20/20 one week after the injection without any additional treatment. Fundus examination and OCT one week after the injection revealed complete absorption of the subretinal fluid (SRF) in the macula. Eighteen months after the injection, vision remained stable and she did not show re-accumulation of SRF in her right eye. Intravitreal injection of bevacizumab may be effective in managing CO associated with SRF without 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.

Anti-vascular endothelial growth factors for choroidal neovascularization secondary to choroidal osteoma: Long-term results

Choroidal osteoma is an uncommon benign osseous intraocular tumor typically seen unilaterally in young women. Visual loss can occur due to choroidal neovascularization (CNV) complicating osteoma. We report a rare case of bilateral choroidal osteoma with secondary CNV in a young male and the long-term results following anti-vascular endothelial growth factor (VEGF) therapy. A 30-year-old male with history of defective vision in both eyes since several years and recent worsening in the right eye (RE) since 2 months was found to have bilateral macular osteoma with CNV in the RE based on clinical evaluation, fluorescein angiography, optical coherence tomography, and ultrasonography. Intravitreal injection of ranibizumab at monthly intervals for three doses resulted in resolution of CNV and remained stable for 5 years. Recurrent CNV detected 6 years later responded to an injection of intravitreal bevacizumab and has remained stable till date. Anti-VEGF therapy stabilized the secondary CNV in our patient for 7 years with satisfactory structural and functional outcome, demonstrating the long-term efficacy of this modality of treatment.

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.

Spontaneous resolution of subretinal hemorrhage secondary to choroidal osteoma unassociated with choroidal neovascularization

Choroidal osteoma is a rare benign intraocular tumor composed of calcification throughout the choroid. Various treatment modalities are available according to location of the tumor and the cause of the visual distortion. We report herein a 30-year-old male who was referred to our hospital with acute blurred vision as a result of the subretinal hemorrhage from choroidal osteoma. We ruled out the presence of CNV and observation was preferred and we prevented unnecessary treatment attempts as spontaneous recovery is the easiest and safest way.

De novo appearance of a choroidal osteoma in an eye with previous branch retinal vein occlusion

This report describes the de novo appearance of a choroidal osteoma occurring 8 years after laser photocoagulation for previous branch retinal vein occlusion (BRVO). A 62-year-old man presented with an asymptomatic yellowish orange lesion in the macula on fundus examination of his left eye during a regular follow-up visit for bilateral BRVO associated with macular edema that had previously been treated with laser photocoagulation. The lesion was observed for 1.5 years until a decrease in vision occurred. Fundus photography revealed a yellow-to-orange, well-defined lesion in the macular region. Fluorescein angiography was consistent with choroidal neovascularization (CNV). Optical coherence tomography and B-scan ultrasonography showed features consistent with choroidal osteoma. This is the first report of the de novo appearance of a choroidal osteoma occurring years after laser photocoagulation for BRVO. CNV developed secondary to the lesion, which was treated with intravitreal bevacizumab, leading to subjective and anatomic improvement.

Treatment of serous macular detachment associated with circumscribed choroidal hemangioma

PURPOSE

To evaluate the effects of transpupillary thermotherapy and intravitreal bevacizumab injection on serous macular detachment and cystoid macular edema (CME) associated with circumscribed choroidal hemangioma.

DESIGN

Retrospective, interventional case series.

METHODS

We reviewed the records of 12 patients with circumscribed choroidal hemangioma treated with transpupillary thermotherapy and/or intravitreal injection of bevacizumab. We assessed changes in best-corrected visual acuity (BCVA), central foveal thickness by optical coherence tomography, and resolution of serous macular detachment and CME.

RESULTS

Six of 8 patients treated with transpupillary thermotherapy showed complete resolution of serous macular detachment and CME and the median minimal angle of resolution (logMAR) BCVA improved from 0.85 to 0.35 (P = .026). Among these 6 patients, 1 had no recurrence for 86 months and 5 had sustained resolution of serous macular detachment for a mean duration of 32.8 months before recurrence. Among the 9 patients treated with bevacizumab (including 5 patients who had transpupillary thermotherapy as a primary treatment), 5 showed resolution of serous macular detachment and the median logMAR BCVA improved from 0.7 to 0.5 (P = .042). Among these 5 patients, 3 had sustained resolution for a mean duration of 5.7 months and 2 showed recurrent serous macular detachment after 3 and 12 months.

CONCLUSION

Transpupillary thermotherapy and intravitreal bevacizumab appear effective in the management of symptomatic circumscribed choroidal hemangioma, although recurrence of serous macular detachment and CME developed after long-term follow-up of transpupillary thermotherapy, and the duration of treatment effectiveness appears to be short with bevacizumab.

Progressive growth of bilateral choroidal osteomas in a child

A 7-year-old girl was referred for retinal dystrophy. On examination, visual acuity was 20/20 in the right eye and 20/30 in the left eye. Fundus examination revealed bilateral orange-colored subfoveal choroidal tumors. Ultrasonography showed calcification, confirming the diagnosis of choroidal osteoma. Because vision was preserved without subretinal fluid or choroidal neovascularization, observation with calcium supplementation was recommended. Three years later, there was minimal tumor growth and visual acuity was maintained. Choroidal osteomas are rare, benign tumors that may decrease vision through decalcification, particularly when subfoveal. In these cases, cautious observation and possibly calcium supplementation may help protect vision.