Choroidal (subretinal) neovascularization secondary to choroidal nevus and successful treatment with argon laser photocoagulation. Case reports and review of literature

Choroidal Neovascular Membranes in Retinal and Choroidal Tumors: Origins, Mechanisms, and Effects

Choroidal neovascularizations are historically associated with exudative macular degeneration, nonetheless, they have been observed in nevus, melanoma, osteoma, and hemangioma involving the choroid and retina. This review aimed to elucidate the possible origins of neovascular membranes by examining in vivo and in vitro models compared to real clinical cases. Among the several potential mechanisms examined, particular attention was paid to histologic alterations and molecular cascades. Physical or biochemical resistance to vascular invasion from the choroid offered by Bruch's membrane, the role of fibroblast growth factor 2 and vascular endothelial growth factor, resident or recruited stem-like/progenitor cells, and other angiogenic promoters were taken into account. Even if the exact mechanisms are still partially obscure, experimental models are progressively enhancing our understanding of neovascularization etiology. Choroidal neovascularization (CNV) over melanoma, osteoma, and other tumors is not rare and is not contraindicative of malignancy as previously believed. In addition, CNV may represent a late complication of either benign or malignant choroidal tumors, stressing the importance of a long follow-up.

Subretinal Choroidal Neovascularization Associated with Choroidal Nevus

Purpose

Evaluation of a large series of choroidal nevi inducing the formation of a neovascular membrane in order to more clearly define the clinical presentation and to evaluate the efficacy of various treatment options.

METHOD

Retrospective study of 22 clinical cases.

Results

All nevi were situated in the posterior choroid. They had a mean diameter of 3.8 mm and a mean thickness of 1.4 mm. Neovascular membranes were classic in all cases, extrafoveal in 13 cases (59%), and subfoveal in 9 cases (41%). A serous retinal detachment was present in every case, hemorrhages were present in 13 cases (59%), and lipid deposits were present in 16 cases (73%). All extrafoveal neovascular membranes were successfully treated by thermal laser photocoagulation. Initial visual acuity was 0.1 in three cases, 0.2–0.4 in five cases, 0.5–0.8 in four cases, and 1.0 or more in two cases. Final visual acuity was 0.1 in one case, 0.2–0.4 in one case, 0.5–0.8 in four cases, and 1.0 or more in seven cases. Five subfoveal neovascular membranes were treated either by thermal laser, photodynamic therapy, or irradiation. No treatment was applied in four cases and in one of these cases, spontaneous resolution of the neovascular membrane was observed. No growth of the pigmented tumor was observed with a mean follow-up of 4.8 years.

CONCLUSIONS

Proliferation of a neovascular membrane on the surface of a pigmented choroidal tumor is a rare complication and is considered to be a relative indicator of a benign nature of the lesion. In the authors' experience, neovascular membranes are extrafoveal in more than half of cases and are accessible to laser photocoagulation. In contrast, the various modalities used to treat subfoveal neovascular membrane were ineffective and functional prognosis was unfavorable in these cases.

Intravitreal bevacizumab associated with photodynamic therapy in a case of polypoidal choroidal vasculopathy associated with choroidal nevus: A case report

RATIONALE

Report the clinical findings and management of a case of polypoidal choroidal vasculopathy associated with choroidal nevus which received combination therapy.

PATIENT CONCERNS

Decreased visual acuity in a woman with polypoidal choroidal vasculopathy and choroidal nevus.

DIAGNOSES

Polypoidal choroidal vasculopathy and choroidal nevus.

INTERVENTIONS

The initial visual acuity was 0.5. After the first treatment with photodynamic therapy, exudation and bleeding appeared around the lesion. After this, the patient received 3 doses of intravitreal bevacizumab.

OUTCOMES

After treatment with combination therapy, visual acuity, clinical and imaging findings improved, with no recurrence of exudation and bleeding.

LESSONS

Intravitreal bevacizumab as an adjunctive treatment after photodynamic therapy is a good option for patients with polypoidal choroidal vasculopathy associated with choroidal nevus.

[Outcome of photodynamic therapy for subretinal neovascularization secondary to choroidal nevi]

INTRODUCTION

Choroidal nevi are the most common benign intraocular tumors. However, the occurrence of subretinal neovascularization secondary to choroidal nevus is very rare. Our goal was to assess the efficacy and the safety of photodynamic therapy (PDT) for treatment of subretinal neovascularization related to choroidal nevi.

PATIENTS AND METHOD

We conducted a retrospective study including subretinal neovascularization secondary to choroidal nevi treated by PDT from 1999 to 2005. PDT was performed according to the standard protocols used for treating neovascularization due to age-related macular degeneration (ARMD). Post-PDT follow-up was also done according to the guidelines used in ARMD. Moreover, tumors were followed up every 3 months.

RESULTS

Six subretinal neovascularizations secondary to choroidal nevi were included in our study. All nevi were localized in the posterior choroids. The median diameter of tumors was 3mm and their thickness was less than 2mm in all cases. Subretinal neovascularizations were classic in five cases. The last case was a small vascularized pigment epithelium detachment. Locations were subfoveal in two cases, juxtafoveal in three cases, and extrafoveal in one case. In half the cases, the size of subretinal neovascularization was 1-disk-diameter or less. A mean of 3.3 sessions of PDT were necessary to obtain the stabilization of subretinal neovascularization on both fluorescein angiography and OCT. The average follow-up period was 35 months with no patients lost to follow-up. Visual outcomes were extremely variable. Large or subfoveal neovascularization but also a history of atrophic ARMD were related to worse functional results. No growth of the nevi was observed.

CONCLUSIONS

Subretinal neovascularization is reassuring from the oncologist's point of view because it is considered a relative indicator of benignity of the nevus. However, it often marks a definitive turning point in visual function. PDT appears to be a safe and effective procedure for the treatment subretinal neovascularization secondary to choroidal nevus, with results similar to those observed in ARMD.

Choroidal neovascular membrane in a series of cases of malignant melanoma of the choroid

PURPOSE

To examine a series of choroidal melanoma specimens to determine the frequency of overlying choroidal neovascularization (CNV) and to ascertain whether CNV over choroidal malignant melanoma is associated with any particular histological tumour characteristics.

METHODS

We carried out a retrospective histological analysis of globes containing choroidal melanomas for evidence of choroidal neovascular membranes.

RESULTS

Microscopic evidence of choroidal neovascular membranes was evident in 6% of cases. Choroidal neovascularization was not associated with any particular histological tumour characteristic.

CONCLUSION

Choroidal neovascularization over choroidal malignant melanoma is not an infrequent occurrence and possibly appears as frequently as CNV over choroidal naevi. The presence of a choroidal neovascular membrane over a pigmented fundal lesion should not be taken as reassurance that the lesion is benign.

VARIABLE OUTCOME OF PHOTODYNAMIC THERAPY FOR CHOROIDAL NEOVASCULARIZATION ASSOCIATED WITH CHOROIDAL NEVUS

PURPOSE

To report five cases of classic choroidal neovascularization (CNV) associated with choroidal nevus treated with photodynamic therapy (PDT) with verteporfin.

METHODS

The patients underwent an ophthalmologic evaluation, including fluorescein angiography and indocyanine green angiography. Clinical and angiographic data were retrospectively analyzed to evaluate visual acuity outcomes and both clinical evolution and angiographic evolution.

RESULTS

Two patients presented with subfoveal CNV, and three had juxtafoveal CNV. The mean follow-up was 25.8 months. Visual outcomes were extremely variable. Indeed, best-corrected visual acuity decreased in three eyes, stabilized in one case, and improved in the other case. The number of PDT sessions necessary to obtain CNV stabilization with cessation of fluorescein leakage varied from one to six.

CONCLUSION

Bearing in mind that both the natural history and the post-PDT outcome may be extremely variable, further studies are needed to assess the real benefit of PDT for classic CNV secondary to choroidal nevus.

Transpupillary thermotherapy for subfoveal choroidal neovascularization associated with choroidal nevus

PURPOSE

To describe a patient with classic subfoveal choroidal neovascularization (CNV) associated with choroidal nevus, which was successfully treated using transpupillary thermotherapy.

DESIGN

Interventional case report.

METHODS

A 53-year-old woman underwent ophthalmologic evaluation, including fluorescein and indocyanine green angiography. Clinical and angiographic data were prospectively analyzed to evaluate visual acuity changes and angiographic evolution.

RESULTS

Three months after transpupillary thermotherapy, visual acuity had improved from 20/100 to 20/40. Fluorescein and indocyanine green angiograms showed absence of leakage from CNV. Final visual acuity was 20/32 after a 15-month follow-up.

CONCLUSIONS

Transpupillary thermotherapy may be a viable option for subfoveal CNV associated with CN, although further studies are needed to establish the correct setting.

Choroidal neovascularization

Choroidal neovascularization is now considered to be a most important feature in the pathogenesis and treatment of a number of chorioretinal disorders. Since the recognition of its importance, choroidal neovascularization has been described in clinical and pathologic studies of a variety of different ophthalmologic conditions. We have summarized the diseases in which choroidal neovascularization occurs and have reviewed studies on the natural history, clinical findings, and therapy of choroidal neovascularization that provide the basis for the current management of this condition.