Novel optical coherence tomography classification of torpedo maculopathy

Type 1 and type 2 torpedo maculopathy

PURPOSE

To analyze torpedo maculopathy (TM) and to report the characteristics of the disease.

METHODS

Retrospective study. The review of a database for clinical diagnosis identified eight patients with TM lesions in the retina between 2016 and 2022. Multimodal imaging was used to analyze the cases.

RESULTS

All cases were unilateral, asymptomatic, and hypopigmented. They were associated by surrounding hyperpigmented retinal pigment epithelium changes to varying degrees. All lesions were located in the temporal retina on the horizontal axis, pointing towards the fovea, except for one patient with a lesion inferior to the fovea. Optical coherence tomography imaging revealed a normal inner retina in all eyes. In the area of the TM lesion, attenuation of the interdigitation zone was seen in mild cases (three cases). All other five patients had thinning of the outer nuclear layer and loss of ellipsoid zone and interdigitation zone of the TM lesion. Four of these cases had a subretinal cavitation/cleft, and two of them additionally an inner choroidal excavation. No patient had any sign of choroidal neovascularization. The average age for patients with type 1 TM was 18 years and for type 2 TM 16.5 years.

CONCLUSION

In this large case series, we could not detect an age difference between the different types of the TM. Contrary to previous discussions, type 2 TM can also occur in young patients.

A unique presentation of subretinal fluid in a type III torpedo maculopathy phenotype

Purpose

To report a rare type III torpedo maculopathy lesion with a unique manifestation of subretinal fluid.

Observations

A nine-year-old patient was referred to retina for an evaluation of a hypopigmented oval-shaped lesion in the temporal macula with an area of inferior subretinal fluid in the right eye. The lesion demonstrated inner and outer retinal and retinal pigment epithelial attenuation, intraretinal and subretinal fluid, a serous neurosensory retinal detachment, and inner choroidal excavation on optical coherence tomography. Fundus autofluorescence showed a lane of downward-tracking fluid. Intravenously administered fluorescein angiography revealed a window defect in the area of the torpedo lesion suggesting choroidal flush.

Conclusions and Importance

The case is the third documented case of torpedo maculopathy with subretinal fluid in the literature with a unique combination of intraretinal cystic changes and dependent descending subretinal fluid, somewhat akin to a Best disease outside of the fovea with choroidal excavation. The morphology of torpedo maculopathy continues to expand as more cases are revealed.

Long-term follow-up of torpedo maculopathy: a case series and mini-review

BACKGROUND

Torpedo maculopathy (TM) is a rare, congenital condition characterized by an oval-shaped, chorioretinal lesion in the temporal macula of unknown etiology. To our knowledge, the longest reported follow-up of TM is 5 years. Herein we report 10 years of follow-up on two patients with TM to further characterize the long-term natural history of the condition.

CASE REPORTS

Two patients with torpedo maculopathy were examined at baseline and then again at 5 years and 10 years from baseline. Eyes were evaluated using color fundus photography, automated perimetry, fundus autofluorescence and spectral domain optical coherence tomography. Visual function of both patients remained stable throughout the observation period. In case 1, there was no evidence of change in lesion morphology over the 10 year observation period. Case 2 showed progression of cystic degeneration of the neurosensory retina within the torpedo lesion. Case 1 reported a history of supernumerary teeth and underwent gene sequence with deletion/duplication analyses of the APC gene but no clinically significant variants were detected.

CONCLUSIONS

Our findings support the position that TM is a nonprogressive condition with long-term stability of visual function. Genetic analysis of case 1 failed to detect any association with Gardner syndrome.

Association of torpedo maculopathy and keratoconus in a young patient: A multimodal imaging study

PURPOSE

To report and document a case of torpedo maculopathy found in a patient affected by keratoconus.Case report: An healthy 16-year-old male patient, affected by keratoconus in both eyes, was referred to the cornea service of our hospital for a follow-up visit.During the dilated fundus examination of the left eye, an oval, well-demarcated, hypopigmented lesion was observed in the juxtafoveal temporal region, pointing towards the center of the macula. Multimodal imaging of the lesion was performed, and the diagnosis of Torpedo Maculopathy was established based on the clinical picture.

CONCLUSION

This is the first case of torpedo maculopathy described in a patient affected by keratoconus. This association may be merely fortuitous or the result of developmental abnormalities affecting both corneal and retinal structures.

CHOROIDAL NEOVASCULARIZATION IN TORPEDO MACULOPATHY TREATED BY AFLIBERCEPT: LONG-TERM FOLLOW-UP USING OPTICAL COHERENCE TOMOGRAPHY AND OPTICAL COHERENCE TOMOGRAPHY ANGIOGRAPHY

PURPOSE

To report a case of torpedo maculopathy (TM) in an elderly patient complicated by choroidal neovascularization (CNV) and that was treated by intravitreal aflibercept injections and monitored during 30 months using optical coherence tomography (OCT) and OCT angiography.

METHODS

A 74-year-old woman complained of a metamorphopsia in the left eye. Visual acuity was 20/25 while fundus examination showed a hypopigmented torpedo-shaped chorioretinal lesion in the temporal macula associated with a retinal exudation.

RESULTS

Multimodal imaging showed a severe chorioretinal excavation confirming the diagnosis of TM associated with an exudative Type 1 CNV. Intravitreal aflibercept injections allowed an initial good anatomical and functional improvement, but multiple recurrences occurred. At the last visit, 30 months after the start of 14 intravitreal aflibercept injections, a persistent subretinal fluid was present with a decreased visual acuity to 20/32 while the CNV surface grew in OCT angiography.

CONCLUSION

This first case of long-term follow-up of CNV secondary to TM showed an anti-VEGF dependency or even a resistance with extension of CNV. Thus, a deep retinochoroidal atrophy could be the late evolution of TM that may result on severe CNV in advanced stages. A regular TM monitoring including OCT and OCT angiography would be necessary to detect any potential CNV for an early and aggressive treatment.

Incidental Unilateral Macular Lesions in Children

BACKGROUND

This study aims to examine the rare entity of unilateral macular lesions in the pediatric population and describe the distinct diagnoses and characterizations related to these findings.

METHODS

A retrospective cohort design. The database of the ophthalmology clinic in a tertiary medical center was reviewed to identify all children with incidental unilateral macular findings, examined during 2016 through 2021.

RESULTS

Twenty children were included. Mean age was 7.8 ± 3.4 years, 50% were girls. The most common macular lesion was torpedo maculopathy (50%), followed by pigmentary changes (25%), discoid maculopathy (15%), macular scar and combined hamartoma of the retina and retinal pigment epithelium (RPE) (5% each). None of the lesions changed after a mean follow-up duration of 2.3 ± 1.5 years. Visual acuity in the involved eye was equal to that in the contralateral eye in 90% of patients and did not change from initial to final visit.

CONCLUSION

Incidental unilateral macular lesions in the pediatric population are usually benign, stable, and do not affect vision. Long-term follow-up is advised, as vision-threatening alterations may appear. [Ophthalmic Surg Lasers Imaging Retina 2023;54:346-352.].

Expanded Spectrum Torpedo Retinopathy: A Case Series

Torpedo lesions in the retina are rare, and their clinical significance has not been well established. This case series highlights patients with atypical torpedo lesions with varying orientations and pigmentation patterns. We describe the first documented case of an inferiorly oriented lesion, to our knowledge, and add to the few previous descriptions of double-torpedo lesions.

Multimodal Imaging of Choroidal Structural in Torpedo Maculopathy

Objective

To report a case of torpedo maculopathy with multimodal fundus imaging methods, and apply the choroid vascularity index to quantitatively describe the choroidal structural changes in torpedo maculopathy.

Case presentation

An asymptomatic 41-year-old Chinese woman with an incidentally found yellowish-white macular lesion in her left eye was referred to our hospital. She was unaware of any prior medical conditions. The best corrected visual acuity (BCVA) was 20/20 OD and 20/25 OS, respectively. Fundus exam of her left eye revealed a well-circumscribed torpedo-like hypopigmented lesion in the macula region, and the tapered edge directed toward the fovea. Pigment deposition could be seen in the inferotemporal portion of the torpedo lesion. Fluorescein angiography showed the corresponding window defect without leakage and fundus autofluorescence demonstrated low signal throughout the lesion. Enhanced depth imaging optical coherence tomography revealed outer retinal attenuation, subretinal cavitation, subtle inner choroidal excavation and thinning of outer nuclear layer. The diagnosis of torpedo maculopathy was clinically made. Choroidal vascularity index (CVI) and sub-foveal choroidal thickness (SFCT) were applied to display changes of choroidal structure. The results implied that both subfoveal CVI and SFCT of the affected eye seemed relatively lower when compared with the fellow eye. Optical coherence tomography angiography showed reduced density of the choriocapillaris in the temporal area of the lesion and increased capillary density in the nasal area. Functional examinations, including microperimetry, multifocal electroretinogram and static perimetry also revealed reduced retinal sensitivity, decreased stimulated amplitude and suspected scotoma in the lesion area. After 12 months of follow-up, the patient's visual acuity and the clinical appearance of the lesion were unchanged.

Conclusion

The torpedo maculopathy may be identified by abnormal appearance with multimodal imaging. Decreased choroidal vascularity in the lesion area measured quantitatively by choroid vascularity index may play a role in pathogenesis of torpedo maculopathy.

Torpedo Maculopathy. A Case Report

AIM

Torpedo maculopathy is an incidental, congenital retinal lesion. The typical clinical finding is a unilateral, symmetric, oval, hypopigmented lesion in the inferotemporal macula. In most cases, the lesion is along the horizontal raphe, is torpedo-shaped, and the nasal edge is directed into the foveola. The diagnosis is determined on the basis of its characteristic shape, localization and findings on optical coherence tomography (OCT). The etiology and pathogenesis of torpedo maculopathy is unclear, but it is believed to be a congenital defect of the retinal pigment epithelium (RPE). The aim of this publication is  highlight this diagnosis and to present an incidental finding of torpedo maculopathy in an adult patient.

CASE REPORT

A 30-year-old female patient reported for a routine eye examination. Fundus examination of the right eye revealed an oval hypopigmented lesion with a size of 1 disk diameter inferotemporally from the fovea, which was followed by a satellite lesion in the same axis directed into the foveola. Based on OCT, OCT angiography, fundus autofluorescence, and the typical shape and location of the lesion, the patient was diagnosed with torpedo maculopathy in the right eye.

CONCLUSION

In general, torpedo maculopathy is an asymptomatic, congenital, benign retinal lesion, which is mostly diagnosed accidentally during a routine fundus examination. TM is non-progressive retinal finding with a minimal risk of deterioration of visual functions, which does not require any treatment. Nevertheless, due to the rare risk of a choroidal neovascular membrane, it is recommended to examine patients once a year. It is necessary to consider this diagnosis when a unilateral hypopigmented lesion is found inferotemporally from the fovea, and to distinguish it from chorioretinal atrophy, scar, vitelliform dystrophy, or other RPE lesions as part of the differential diagnosis.

Multimodal imaging of torpedo maculopathy with optical coherence tomography angiography

A 24-year-old woman presented for routine clinical evaluation. Her best-corrected visual acuity was 20/20 and slit-lamp examination of the anterior segment was normal in both eyes. Fundus examination of the left eye revealed a hypopigmented lesion, one disc diameter temporal to the fovea, with a hyperpigmented tail extending temporally from the main lesion, consistent with a torpedo maculopathy. Fundus autofluorescence showed an hypoautofluorescence with hyperautofluorescent border. Swept-source optical coherence tomography (OCT) showed a normal inner retina and a degeneration of the outer retina without retinal cavitation. OCT angiography (OCT-A) of the choriocapillaris layer revealed reverse shadowing caused by the increased transmission from the atrophied outer retina and RPE within the torpedo lesion and attenuation of signal in the area of the temporal hyperpigmentation. The superficial capillary plexus was normal. This case includes a multimodal imaging with OCT-A of torpedo maculopathy in a Tunisian woman. Further reports are required to provide a better understanding of this rare condition.

Multimodal Imaging of Torpedo Maculopathy With Fluorescence Adaptive Optics Imaging of Individual Retinal Pigmented Epithelial Cells

Torpedo maculopathy (TM) is a rare congenital defect of the retinal pigment epithelium (RPE). The RPE is often evaluated clinically using fundus autofluorescence (AF), a technique that visualizes RPE structure at the tissue level from the intrinsic AF of RPE fluorophores. TM lesions typically emit little or no AF, but this macroscopic assessment is unable to resolve the RPE cells, leaving the organization of the RPE cell mosaic in TM unknown. We used fluorescence adaptive optics scanning laser ophthalmoscopy (AOSLO) to show here for the first time the microscopic cellular-level structural alterations to the RPE cell mosaic in TM that underlie the tissue-level changes seen in conventional clinical imaging. We evaluated two patients with TM using conventional clinical imaging techniques and adaptive optics (AO) infrared autofluorescence (IRAF) in AOSLO. Confocal AOSLO revealed relatively normal cones outside the TM lesion but altered cone appearance within it and along its margins in both patients. We quantified cone topography and RPE cell morphometry from the fovea to the margin of the lesion in case 1 and found cone density to be within the normal range across the locations imaged. However, RPE morphometric analysis revealed disrupted RPE cells outside the margin of the lesion; the mean RPE cell area was greater than two standard deviations above the normative range up to approximately 1.5 mm from the lesion margin. Similar morphometric changes were seen to individual RPE cells in case 2. Multi-modal imaging with AOSLO reveals that RPE cells are abnormal in TM well beyond the margins of the characteristic TM lesion boundary defined with conventional clinical imaging. Since the TM fovea appears to be fully formed, with normal cone packing, it is possible that the congenital RPE defect in TM occurs relatively late in retinal development. This work demonstrates how cellular level imaging of the RPE can provide new insight into RPE pathologies, particularly for rare conditions such as TM.

Case Report: Use of Multimodal Imaging to Document a Rare Complication of Torpedo Maculopathy

SIGNIFICANCE

This study demonstrates the importance of routine multimodal imaging for the diagnosis of choroidal neovascular membrane secondary to torpedo maculopathy.

CASE REPORT

A 63-year-old woman with a history of torpedo maculopathy presented with recent-onset symptoms of visual distortion in the right eye. Multimodal imaging modalities revealed the presence of a choroidal neovascular membrane. The choroidal neovascular membrane was treated, and the patient was subsequently followed up to monitor the retinal appearance over time. Significant structural restoration of the macular anatomy with overall functional improvement was seen.

CONCLUSIONS

Although torpedo maculopathy is often a benign diagnosis, complications such as choroidal neovascular membrane can occur. Choroidal neovascular membrane formation is well documented in younger patients with torpedo maculopathy; however, we present a rare case of choroidal neovascular membrane in an elderly individual. Multimodal imaging proved instrumental in the early detection and management of this infrequently reported complication.

Clinical evaluation of torpedo maculopathy in an infant population with additional genetic testing for NEXMIF mutation

PURPOSE

To assess clinical characteristics of torpedo maculopathy (TM) lesions in an infant population with age ≤1.5 years and to investigate the role of NEXMIF mutation in the development of TM.

METHODS

Retrospective analysis of medical records of 17 consecutive infants with the diagnosis of TM between 2016 January and 2019 December were done. Fundus images and a hand-held spectral-domain optical coherence tomography (Envisu 2300, Bioptigen, Morrisville, NC, USA) were used to identify clinical characteristics of TM lesions. Additional molecular testing for mutation screening for NEXMIF gene was also carried out.

RESULTS

Totally 55334 infants were screened during the study period and 17 (0.03%) were identified as having TM. The mean age at the time of diagnosis was 3.94±5.08 months. All TM lesions showed variable degrees of hypopigmentation. Satellite lesion in one infant was nasally located to the main TM lesion. Absence, disruption, loss, degeneration and/or irregularity of the ellipsoid zone were common findings on OCT examination. No pathogenic or likely pathogenic variant of NEXMIF gene was detected.

CONCLUSION

Fundoscopic appearance and OCT findings of lesions show similarities to those already reported previously. Contrary to popular belief, a nasally located satellite lesion was observed in one of our case.

Torpedo-like lesions in the ocular fundi of Gardner syndrome: hiding in plain view

Background: The coexistence of fundus torpedoes and Gardner syndrome was initially reported in 1989 and 1992 by Gass and Roseman. Gardner syndrome is a dominantly inherited disease characterized by a multitude of potentially lethal gastrointestinal polyps. Over the ensuing quarter century, several publications demonstrated uncommon, but easily recognized, fundus lesions called Torpedo Maculopathy in apparently normal individuals. These fundus abnormalities were thought to be single and isolated without systemic associations. During the same period of time, a variety of nonspecific fundus abnormalities were described in Gardner syndrome, which, in retrospect, included highly specific lesions that closely resembled macular torpedoes and sometimes were indistinguishable from them.Patient and methods: We now report a confirmed case of Gardner syndrome with numerous fundus torpedoes, and carefully analyze the voluminous literature of both Gardner syndrome and Torpedo Maculopathy.Results: We demonstrate shared features of the fundus lesions in both diseases, and hypothesize that they may have genetic as well as ophthalmoscopic similarities in common.Conclusions: We therefore recommend that individuals with classic isolated torpedoes undergo evaluations for mutations in the Gardner gene (Adenomatous polyposis coli) and for the presence of gastrointestinal polyps and other systemic features of Gardner syndrome. We also suggest that apparently normal individuals, who are genetically related to patients with known classic torpedoes, undergo inspection of their fundi for the possible presence of characteristic lesions.

Coexistence of torpedo maculopathy and retinoblastoma: Differentiation the lesions with hand-held optical coherence tomography

Torpedo maculopathy (TM) is a rare congenital defect of the retina pigment epithelium, which always localizes to the temporal fovea. It is most commonly unilateral and often occurs in patients without any relevant disease. Classic finding is a flat, hypopigmented, oval lesion, resembling a 'torpedo,' with a wedge-shaped tail extending outward and directed toward the foveola. Visual acuity is generally unaffected due to the central fovea is not involved and this lesions remain stable. Therefore, when it accompanied with a posterior segment disease, we should make differential diagnosis to avoid unnecessary treatment. Herein, we present a child with coexistence of TM and retinoblastoma, and how to manage the lesions. We aimed to alert the ophthalmologists to this unusual combination for avoiding unnecessary treatment modalities. To the best of our knowledge, this combination that has never before been described.

Adaptive optics ophthalmoscopy, multifocal ERG and OCTA in unique case of suspected torpedo maculopathy presenting with vitelliform lesion

Purpose

To report the case of a ten-year old girl with torpedo maculopathy with a complete vitelliform lesion and describe associated optical coherence tomography (OCT), OCT angiography (OCTA), multifocal electroretinogram (ERG) and adaptive optics ophthalmoscopy (AOO) imaging of the lesion.

Observations

An asymptomatic ten-year old girl with visual acuity of 20/15 OU was referred for evaluation of possible Best's disease of her left eye. The unilaterality, location, and shape of the lesion was consistent with torpedo maculopathy. OCT and autofluorescence (AF) revealed that the entire lesion was composed of subretinal hyperreflective material that was hyperautofluorescent, consistent with vitelliform material. Within the boundary of the lesion, OCTA showed reduced choriocapillaris density while adjacent to the lesion, the choriocapillaris density was slightly increased. Microperimetry demonstrated normal sensitivity in both eyes, electrooculograms (EOG) were normal and multifocal ERG showed symmetrical mildly supernormal amplitudes. Additionally, AOO demonstrated that nasal to the lesion there were clusters of hyper-reflective areas, and immediately adjacent to the lesion cones were poorly resolved. However, there was a return to more normal photoreceptor architecture outside of the lesion.

Conclusions and Importance

Torpedo maculopathy lesions typically present with outer retinal attenuation and retinal pigmented epithelium (RPE) atrophy. Vitelliform material was recently observed for the first time in association with Torpedo maculopathy in a case report that described small vitelliform material at the periphery of the lesion. We report the second case of torpedo maculopathy associated with a vitelliform lesion and the first description of a torpedo lesion composed fully of presumed vitelliform material. We also describe findings of OCTA, multifocal ERG and AOO imaging in torpedo maculopathy with vitelliform lesion.

A novel phenotype of torpedo maculopathy on spectral-domain optical coherence tomography

Purpose

To present a new phenotype of torpedo maculopathy on spectral domain optical coherence tomography imaging (SD-OCT).

Observations

A 31-year-old female presented with a multi-partite yellowish lesion in the macula of her left eye, with a central fovea-involving component and a temporal tail-like component. The lesion showed mixed hyper- and hypoautofluorescence on fundus autofluorescence imaging. The fovea-involving component exhibited disruption of ellipsoid zone without outer-retinal cavitation on SD-OCT, consistent with the prior-described type 1 OCT morphology. The temporal tail showed subtle inner choroidal excavation with preservation of the ellipsoid zone and outer-retinal structures.

Conclusions

Inner choroidal excavation with preservation of the overlying outer-retinal structures represents a novel morphological phenotype on SD-OCT in torpedo maculopathy. This case demonstrates that distinct morphological subtypes may co-exist in different regions of the same torpedo maculopathy lesion.

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.

Choroidal Cavitary Disorders

The structure and functions of the choroid have been long acknowledged but the pathophysiology behind various anomalies has been difficult to understand until the advent of optical coherence tomography (OCT). With OCT imaging, choroidal cavitations appear as optically empty spaces between the outer retinal and choroidal layers with attenuation or loss of outer retinal layers. Choroidal cavitations are found in the posterior pole and seen in conditions such as pathologic myopia, north carolina macular dystrophy (NCMD), focal choroidal excavation (FCE), and torpedo maculopathy (TM). To date, these disorders have not been linked. A commonality they all share is malformation of the RPE-photoreceptor-choroid complex. The following report describes the differences and similarities of choroidal cavitation amongst the different retinal disorders and emphasizes the importance of multimodal imaging in the detection and management of potential complications.

[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.

Torpedo Retinopathy

Purpose

Torpedo lesions in the retina are rare. This study aimed to investigate torpedo-shaped lesions in the retina in an adult population and to determine the spectrum and features of the disease.

Methods

The review of a database for clinical diagnosis identified nine patients who were diagnosed with torpedo-shaped lesions in the retina between June 2017 and February 2019. Fundus photography and optical coherence tomography (OCT) imaging were used to analyze the cases. Multicolor imaging was also performed.

Results

Nine patients with torpedo-shaped lesions in the fundus were identified. Fundus images revealed that the lesion involved the macula in six eyes; in the remaining three eyes, the lesion was present outside the macula. OCT identified six patients with type 1 torpedo lesions, one with type 2, and two with type 3. On multicolor imaging, the lesion was visualized as a region of increased reflectance in blue, green, and infrared light in all eyes, with notably increased infrared reflectance in eyes with focal choroidal excavation. Choroidal neovascular membrane was evident in one patient on OCT angiography.

Conclusion

Torpedo lesions in the retina can occur away from the macula and exhibit features similar to those of torpedo maculopathy. As such, the authors propose a change in the nomenclature for torpedo lesions in the retina from "torpedo maculopathy" to "torpedo retinopathy."

Ocular manifestations in Congenital Zika syndrome: About a case of torpedo maculopathy

Purpose

To describe pertinent imaging studies and clinical features of a torpedo maculopathy presumably associated with congenital Zika syndrome.

Observation

A 23-month-old child, with no prematurity or microcephaly at birth, was examined in the Ophthalmology department of the University Hospital of Fort-de-France (Martinique, French West Indies), as part of a systematic screening of malformations in children suspected of maternal-fetal exposure to Zika virus. Zika infection was confirmed in the mother's serum by Reverse Transcriptase Polymerase Chain Reaction during the third trimester of pregnancy. Fundus examination found a unilateral hypopigmented retinal lesion, temporal to the macula, with an apex pointing to the fovea. Explorations in spectral-domain optical coherence tomography showed a subretinal cleft with broadening and attenuation of the interdigitation zone, elevation of the outer limiting membrane and the ellipsoid zone, without thinning of the outer retinal layers.

Conclusion and importance

There is a proven risk of congenital eye defects after Zika infection during pregnancy. We report here the first case of torpedo maculopathy without microcephaly, in a child suspected of maternal-fetal exposure to Zika.

Torpedo maculopathy: A case series - insights into basic pathology

Torpedo maculopathy is a benign retinal disorder whose pathophysiological origins are currently poorly understood. A number of theories have been postulated, with stable developmental anomalies of the retinal pigment epithelium taking the forefront. Four clinical cases are outlined of patients with macular torpedo lesions, with differing clinical presentation. In all four cases, this reveals very thin retinal pigment epithelium and outer retina associated with the lesion. In a single case, the oldest patient of the group, there is the additional finding of subretinal and intraretinal fluid accumulation. The contrast between this case and the other cases suggests that while initially this benign pathology might start with structurally normal retina with no fluid accumulation, dysgenetic changes in the retinal pigment epithelium might lead to secondary accumulation of fluid over time. Whether indeed this disorder might be progressive in nature, or whether in fact it is a static, non-progressive developmental abnormality as formerly thought, requires further elucidation.

Structural-functional correlation using adaptive optics, visual fields, optical coherence tomography and multifocal electroretinogram in a case of torpedo maculopathy

We present a case of a 37-year-old gentleman with a rare diagnosis of Torpedo maculopathy (TM). We describe the multimodal imaging features of torpedo maculopathy using adaptive optics, visual fields, OCT and multifocal ERG, and understand the clinical and structural-functional correlation in TM. According to us, this is the first case report to describe the adaptive optics imaging findings in Torpedo maculopathy in English Medical literature.

Distribution patterns of torpedo maculopathy: Further evidence of a congenital retinal nerve fiber layer-driven etiology

With fewer than 100 peer-reviewed cases reported in the world to date, the underlying etiology of torpedo maculopathy has remained elusive. In this literature review, we provide new evidence to better support, reject and unify claims regarding cause, diagnosis, and proper clinical management of this disease. We reviewed 44 case reports and case series, which included 77 patients (after exclusions). We additionally introduced 3 new cases from our clinical practice for a total of 80 cases. Ages at presentation ranged from 6 months old to 73 years old (mean: 24.2 years old). The nasal aspects of torpedo maculopathy lesions pointed toward the optic disc and localized to a kite-shaped region of the temporal macula, correlating with the anatomic junction of the superior arcuate, inferior arcuate, and papillomacular bundles of retinal nerve fiber layer distribution. No patterns were observed among the temporal aspects of the lesions. These findings support a congenital etiology of torpedo maculopathy and a possible influence of the retinal nerve fiber layer in the development of mature retinal pigment epithelium.

Multimodal imaging of torpedo maculopathy in a Chinese woman: a case report

Background

Torpedo maculopathy is a rare, benign, and congenital macular lesion that typically appears in a ‘torpedo-shape’ and is located at the temporal macula region. This study aimed to describe in detail regarding torpedo maculopathy in a Chinese woman using multimodal imaging.

Case presentation

A 30-year-old Chinese woman with occasional yellowish-white macular lesions in her right eye during a routine examination was presented to our hospital. She had no other symptoms, and the best-corrected visual acuity of both eyes was 6/6. Funduscopic examination revealed a torpedo-shaped and mild hypopigmented lesion in the temporal macular area of her right eye. Infrared fundal (IR) images showed visible lesion contour, transverse elliptical, and with a tip pointing towards the central fovea of the macula. Microperimetry visual field appeared normal. The spectral-domain optical coherence tomography (SD-OCT) showed a normal inner retina, with mild thinner outer retina and retinal pigment epithelium in the temporal macular area, and correspondingly increased choroidal reflectivity. Other OCT findings included outer retinal loss/attenuation with significant atrophy of an intact ellipsoid zone. OCT angiography (OCTA) of choroid capillary layer revealed increased density of choroidal vasculature in corresponding to the area of the lesion, while the superficial and deep layers revealed normal vasculature. Fundus autofluorescence (FAF) revealed normal signal with slight hyperautofluorescence at the nasal lesion margin. Fundus fluorescence angiography (FFA) of the lesion showed variegated fluorescence and no leakage and change in the morphology during the whole imaging process.

Conclusions

This is the first report to include a thorough and detailed description of torpedo maculopathy by using fundal photograph, IR, microperimetry visual field, OCT, OCTA, FAF, and FFA. Multimodal imaging provides precious and detailed information to further clarify the characteristics and development of this rare disease.

Multicolor imaging findings in torpedo maculopathy

We describe the multicolor imaging findings in two cases of Torpedo maculopathy (TM). Multicolor imaging can be a useful tool in identifying the level of retinal and choroidal layer involvement in TM. This imaging modality further confirms the hypothesis that TM is a localized congenital abnormality of retinal pigment epithelium pigmentation which leads to outer retinal and inner choroidal degeneration.

Choroidal Neovascularization in Torpedo Maculopathy Assessed on Optical Coherence Tomography Angiography

Torpedo maculopathy is characterized by a congenital, unilateral, and torpedo-shaped chorioretinal lesion with unclear pathogenesis and evolution. Although the optical coherence tomography angiography (OCTA) characteristics have already been defined in literature, the authors describe for the first time the presence of choroidal neovascularization (CNV) on the temporal edge of this lesion in a 36-year-old woman with a history of altered visual field in her left eye. The authors' investigation supports the hypothesis of an aberrant choroidal circulation underlying the pathogenesis of this condition, and proves the advantage conferred by OCTA in CNV detection over the other angiographic techniques. [Ophthalmic Surg Lasers Imaging Retina. 2018;49:e210-e213.].

OPTICAL COHERENCE TOMOGRAPHY ANGIOGRAPHY FEATURES OF TORPEDO MACULOPATHY

BACKGROUND/PURPOSE

To investigate the retinal and choroidal vasculature in patients with torpedo maculopathy with optical coherence tomography-angiography (OCT-A).

METHODS

Retrospective case series of four patients who were examined at the department of Ophthalmology at the University Hospital Bern. Main Outcome was the lesion size over time in OCT-A and fundus autofluorescence.

RESULTS

Three patients had Type I and 1 patient had Type II torpedo maculopathy. Torpedo maculopathy lesion size remained stable in all patients over a mean period of observation of three years in OCT-A and fundus autofluorescence. The choriocapillaris network was attenuated focally within the lesion in OCT-A in all four cases. The lesion size in fundus autofluorescence was 2.77 mm and therefore comparable with the lesion size in OCT-A of 2.75 mm.

CONCLUSION

OCT-A signal of the choriocapillaris was reduced within the cleft in both types of torpedo maculopathy. Whether the changes represent the primary site of malformation or whether these findings are the consequence of a defect in the retinal pigment epithelium remains speculative.

Multimodal imaging of torpedo-shaped fundus lesions: New insights

The purpose of this case series is to describe the varied presentation of Torpedo lesions of the fundus and multimodal imaging features in three eyes of three patients. Two patients presented with typical topography, i.e., temporal to the fovea. One patient revealed lesion inferonasal to disc with the head pointing toward the disc. All three patients had an attenuation of outer retinal layers on optical coherence tomography. One patient showed an additional large subretinal cleft. Variable hypoautofluorescence in the area of the torpedo was noted. To conclude torpedo lesions can present at atypical locations, have both retinal and choroidal atrophy and head point toward the optic disc.

MULTIMODALITY IMAGING OF TORPEDO MACULOPATHY WITH SWEPT-SOURCE, EN FACE OPTICAL COHERENCE TOMOGRAPHY AND OPTICAL COHERENCE TOMOGRAPHY ANGIOGRAPHY

PURPOSE

Multimodality image analysis of two cases of torpedo maculopathy.

METHODS

Imaging with fundus photography, autofluorescence (AF), swept-source optical coherence tomography (OCT), en face OCT, and OCT angiography.

RESULTS

The basal diameter of the torpedo lesions was 1 mm × 2 mm. One case had a satellite lesion. Autofluorescence indicated variable loss of signal. Swept-source OCT and en face OCT demonstrated fundus excavation, attenuation of nuclear layers and disruption of the outer plexiform layer, loss of photoreceptors and a subretinal cleft. In one case, Sattler layer appeared extended at the cleft. Optical coherence tomography angiography indicated loss of flow in deep retinal vessels and increased flow in choroidal vessels surrounding the cleft.

CONCLUSION

Multimodal imaging findings of torpedo maculopathy include disruption of the deep retinal capillary network, expansion of Sattler layer, and increased signal around the subretinal cleft.

Torpedo maculopathy: A primary choroidal capillary abnormality?

A 26-year-old healthy male patient's fundus revealed findings consistent with torpedo maculopathy. Swept-source optical coherence tomography (OCT) showed a dome-shaped elevation of the retina at the level of ellipsoid zone. On OCT angiography segmented at the level of the choriocapillaris, a cluster of convoluted fine vessels was seen, and further, deeper scans of the larger choroidal vessels showed a slower flow. From these observations along with the embryological correlation of choriocapillaris development, a possibility of an abnormality preventing proper fenestration of the choriocapillaris along the horizontal raphe being responsible for this anomaly is suggested.

Torpedo maculopathy: disease spectrum and associated choroidal neovascularisation in a paediatric population

PURPOSE

Torpedo maculopathy is a rare lesion of the retinal pigment epithelium. This study set out to look at these lesions in the paediatric population and determine the spectrum and features of the disease.

METHODS

The paediatric ophthalmology database was used to identify eight children with torpedo maculopathy between 2012 and 2017. Fundal images and optical coherence tomography (OCT) was used to analyse the cases.

RESULTS

Eight patients with torpedo maculopathy were identified, making the prevalence approximately 2 per 100,000 population under 16 years old. The OCT images were classified using the previously described subtypes: Type 1 in patients 5 and 6 and Type 2 in patients 1, 2, 3, 4 and 8. The average age of presentation of Type 1 and Type 2 lesions was 8 and 7 years old respectively. We also report patient 8, who is the youngest reported case of choroidal neovascular membrane associated with torpedo maculopathy. Good anatomical response to a single injection of anti-Vegf was shown.

CONCLUSIONS

This study is the first case series of torpedo maculopathy in the paediatric population. Contrary to previous reports of two distinct types of lesion on OCT representing different stages of the same disease, our case series indicates that Type 1 and Type 2 lesions are in fact different phenotypic entities both of which can occur at a young age. We also present the associated risk of choroidal neovascular membrane formation which is an important consideration for long term follow-up.

Morpho-functional evaluation of torpedo maculopathy with optical coherence tomography angiography and microperimetry

Purpose

To report the case of a 13-year-old girl with torpedo maculopathy, evaluated with multimodal morpho-functional retinal imaging, including fundus photography, infra-red and blue fundus autofluorescence, swept-source optical coherence tomography (OCT), en face OCT, OCT angiography and microperimetry (MP).

Observations

On fundus examination, a torpedo-like hypopigmented lesion was observed temporal to the fovea in the left eye. OCT showed disruption of outer retinal layers and the presence of a subretinal cleft. On OCTA, a diffuse attenuation of signal from choriocapillaris was observed along the lesion. Functional analysis with MP revealed a reduction of retinal sensitivity over the lesion.

Conclusions

and importance: On OCTA, torpedo maculopathy is characterized by vascular alterations of the choriocapillaris along the lesion.

[Torpedo macu-lopathy (clinical case)]

The article presents a clinical case of torpedo maculopathy. This congenital disorder is most likely to be caused by changes in the retinal pigment epithelium (RPE) during retinal fissure closure. Visual function is usually unaffected and the condition is revealed at routine ophthalmic examination in children and teens. Optical coherence tomography showed the absence of RPE, photoreceptor damage, and massive thinning of the outer nuclear layer at the diseased site without a significant change in the total retinal thickness. RPE involvement was also evidenced by changes in fundus autofluorescence.

Torpedo Maculopathy in a 6-Month-Old Infant: Early Clinical and Optical Coherence Tomography Findings

A 6-month-old male infant presented for routine ophthalmologic examination. Indirect ophthalmoscopy revealed a flat, oval, hypopigmented lesion located in the temporal macula in the right eye with the tip pointing toward the fovea, which was compatible with torpedo maculopathy. Optical coherence tomography (OCT) was performed at the time of diagnosis. OCT scans of the lesion revealed slight retinal pigment epithelium hyperreflectivity. This case serves as the earliest OCT finding of the youngest patient diagnosed as having torpedo maculopathy in the literature. [J Pediatr Ophthalmol Strabismus. 2017;54:e54-e57.].