Subretinal Choroidal Neovascularization Associated with Choroidal Nevus

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.

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.

Management of Choroidal Neovascular Membranes Associated with Choroidal Nevi

PURPOSE

To evaluate the management options for choroidal neovascular membrane (CNVM) associated with choroidal nevus.

DESIGN

Cohort study.

PARTICIPANTS

Twenty-four eyes with CNVM associated with choroidal nevus.

METHODS

Retrospective review of demographic and clinical features and management and outcome of eyes with CNVM associated with choroidal nevus.

MAIN OUTCOME MEASURES

Choroidal neovascular membrane status, subfoveal retinal thickness, and visual outcome.

RESULTS

Choroidal neovascular membrane was classic in 20 eyes (83%) and occult in 4 eyes (27%). Of 15 eyes (63%) treated with intravitreal bevacizumab injections, complete regression of CNVM was observed in 6 eyes (40%) and partial regression was achieved in 5 eyes (33%). Visual acuity improved or remained stable in these eyes, and the mean subfoveal retinal thickness decreased significantly from 477 μm to 326 μm. Four eyes (27%) with unresponsive, active CNVM were treated with combined photodynamic therapy (PDT) and bevacizumab therapy; complete or partial regression was observed in 3 eyes with improved or stable visual acuity, and the mean subfoveal retinal thickness decreased from 441 μm to 350 μm. Of 5 eyes (33%) treated with PDT, 4 (80%) showed partial regression. Visual acuity remained stable in these eyes and the mean subfoveal retinal thickness decreased from 370 μm to 334 μm. In 4 eyes with non-vision-threatening CNVM (17%), complete or partial regression was seen in 2 eyes, and CNVM remained active in 2 eyes after observation. Visual acuity remained stable. No significant difference was found between the mean subfoveal retinal thickness at presentation and at the last visit. All choroidal nevi remained stable in thickness and size after a mean follow-up of 30 months.

CONCLUSIONS

Intravitreal bevacizumab injection was effective in achieving complete or partial regression of CNVM in 73% of eyes with improved visual acuity and decreased subfoveal retinal thickness. Combined PDT and bevacizumab therapy led to further regression in eyes that had failed treatment with bevacizumab previously. Some cases of choroidal neovascularization associated with choroidal nevi did not seem to threaten the vision.

Photodynamic therapy for polypoidal choroidal vasculopathy secondary to choroidal nevus

We report a case of a Caucasian female who developed active polypoidal choroidal vasculopathy (PCV) at the edge of a stable choroidal nevus and was successfully treated with verteporfin photodynamic therapy. No active polyp was detectable on indocyanine green angiography 2 years after treatment, and good vision was maintained. Indocyanine green angiography is a useful investigation to diagnose PCV and may be underutilized. Unlike treatment of choroidal neovascularization secondary to choroidal nevus, management of PCV secondary to nevus may not require intravitreal anti-vascular endothelial growth factor therapy. Photodynamic monotherapy may be an effective treatment of secondary PCV.

Treatment of vascular activity secondary to atypical choroidal nevus using intravitreal bevacizumab

Objective

To report the optical coherence tomography (OCT) findings of 27 eyes treated with intravitreal bevacizumab for intraretinal and subretinal vascular activity associated with atypical choroidal nevi.

Methods

This was an Internal Review Board-approved retrospective review of 27 eyes of 27 patients with choroidal nevus treated for secondary vascular activity with intravitreal injections of bevacizumab, performed by a single surgeon (TGM) at the Bascom Palmer Eye Institute. All patients were rigorously evaluated before the procedure and followed thereafter with ophthalmic examinations, refractive analysis, fundus photos, optical coherence tomography (OCT), and ocular echography. Patient demographics, tumor characteristics, dates of bevacizumab injections, and spectral-domain (SD)-OCT findings at each injection were recorded. Macular edema was graded as per SD-OCT findings for the initial and final visit.

Results

The mean age was 66.6 years (range, 40–86 years), with ten males and 17 females. Mean, median, and range baseline best corrected visual acuity (BCVA) were 20/53, 20/40, and 20/20–4/200, respectively. After a mean follow up of 29 months, the final BCVA mean, median, and range were 20/50, 20/40, and 20/20–20/400, respectively. The final BCVA ranged from 20/20 to 20/25 in nine eyes, while only six eyes had an initial BCVA within the same range. All patients demonstrated OCT findings of vascular activity suggestive of choroidal neovascularization (CNV). Initial SD-OCT findings included intraretinal cysts in eleven eyes, intraretinal fluid in six eyes, subretinal fluid in 14 eyes, pigment epithelial detachment in six eyes, epiretinal membrane in five eyes, and subretinal neovascularization in 14 eyes. On fundus photos, four eyes presented retinal hemorrhage. A mean of eight (range of 1–31) intravitreal bevacizumab (1.25 mg/0.05 cc) injections were given in all cases. A total of 37% (10/27) of eyes had complete or partial regression of vascular activity. The mean initial OCT classification for macular edema was 3 and a mean grade of 3 was maintained at the final follow-up OCT. All 27 choroidal nevi remained stable, and there were no adverse effects from the bevacizumab injections.

Conclusion

To our knowledge, this is the largest published case series of eyes treated with intravitreal bevacizumab for vascular activity associated with choroidal nevus. Intravitreal bevacizumab seems to be effective in the treatment of CNV secondary to choroidal nevus, and OCT can be a useful tool in the follow up of these patients, to assess the regression of CNV and to monitor macular edema.

Choroidal naevi complicated by choroidal neovascular membrane and outer retinal tubulation

AIMS

To present the outcomes of a series of patients with choroidal neovascular membrane (CNV) secondary to a choroidal naevus and report the presence of outer retinal tubulation.

METHODS

In this retrospective series, patients underwent a complete clinical and imaging assessment (fundus photo, fluorescein angiography and optical coherence tomography) and were observed or managed with intravitreal anti-VEGF injections dependent on whether visual acuity was affected.

RESULTS

Seventeen patients were included in this study. Of this, 46% (8/17) had classic or predominantly classic CNV and 53% (9/17) had occult or minimally classic CNV. Active treatment with intravitreal anti-VEGF injections was required in 35% (6/17). Visual acuity improved in three eyes by 2-4 Snellen lines, remained stable in one eye and worsened in two eyes by 2 Snellen lines. CNV partially regressed in five cases. In the observation group (65%, 11/17), visual acuity did not change during follow-up period. Outer retinal tubulation was found in 18% (3/17).

CONCLUSIONS

Anti-VEGF treatment is effective in the management of vision threatening CNV secondary to a choroidal naevus. Functional or anatomical improvement was obtained in 66% of treated eyes. Outer retinal tubulation, noted in 18%, showed the clinical importance of this sign in determining continuation of anti-VEGF treatment.

Photodynamic therapy in a case of polypoidal choroidal vasculopathy associated with choroidal nevus

PURPOSE

The purpose of this study was to report the clinical findings and management of a case of polypoidal choroidal vasculopathy associated with choroidal nevus.

METHODS

A 59-year-old woman with a subfoveal vascular network with polypoidal lesions associated with choroidal nevus was treated with photodynamic therapy. The initial visual acuity was 1/60. Treatment was performed according to identical parameters to those used for choroidal neovascularization secondary to age-related macular degeneration and was repeated 3 months after the first application. The patient was prospectively followed with optical coherence tomography, fluorescein angiography, and indocyanine angiography.

RESULTS

After the second treatment, total occlusion of the polypoidal lesions was observed but the vascular network remained still patent. During the 5-year follow-up, no recurrence was observed and the visual acuity rose to 1/10.

CONCLUSION

In our experience, photodynamic therapy had positive results and this indicates the possibility that it could be a useful tool to manage these lesions and to improve their prognosis.

Large turbid retinal pigment epithelial detachment camouflaging an underlying choroidal nevus

PURPOSE

To report an unusual large turbid detachment of the retinal pigment epithelium (RPE) overlying a hidden choroidal nevus.

METHODS

Case report.

RESULTS

A 51-year-old woman was referred with an asymptomatic yellow subretinal mass in the left eye presumed to represent a choroidal metastasis or melanoma. Visual acuity was 20/20 in both eyes. Ophthalmoscopy of the left eye revealed a well defined, abruptly elevated, dome-shaped amelanotic lesion temporal to the macular area measuring 4 mm in basal dimension and 2.2 mm in thickness. There was no evidence of drusen, inflammation, or hemorrhage. Fluorescein angiography and optical coherence tomography suggested RPE detachment from unknown cause. After 6 years follow-up, the RPE detachment resolved, exposing an underlying chronic choroidal nevus as the etiology.

CONCLUSIONS

Choroidal nevus can produce an overlying RPE detachment that completely obscures the underlying lesion.

[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.