Tumors and Related Lesions of the Pigmented Epithelium

Multifocal Congenital Simple Hamartoma of the Retinal Pigment Epithelium: A Multimodal Imaging Case Study

Congenital simple hamartoma of the retinal pigment epithelium (CSHRPE) is a rare benign tumor often detected incidentally during routine eye exams. We present a case of multifocal CSHRPE in a 32-year-old Hispanic woman, emphasizing the diagnostic challenges posed by its presentation and the pivotal role of multimodal imaging in accurate diagnosis. Despite initial difficulties due to a history of trauma and pigmented fundus, advanced imaging techniques, including optical coherence tomography (OCT), OCT angiography (OCTA), fluorescein angiography (FA), and indocyanine green angiography (ICGA), facilitated a precise diagnosis. Notably, OCTA revealed high signal intensity and flow at the largest nodule site while FA and ICGA exhibited characteristic blockage patterns. Moreover, smaller nodules exhibited OCT findings supporting the theory of islands of retinal pigment epithelium (RPE) cells proliferating ectopically within the retina. Our case underscores the importance of comprehensive imaging assessment in distinguishing CSHRPE from other lesions, contributing to a deeper understanding of this rare ocular condition.

Nonpigmented Adenoma of the Retinal Pigment Epithelium Mimicking a Retinal Vasoproliferative Tumor Managed With Endoresection

Purpose: To present a case with signs suggestive of a retinal vasoproliferative tumor. Methods: A case report was evaluated and a surgical video presented. Results: A 61-year-old White man presented with an amelanotic retinal tumor associated with exudation, retinal edema, and overlying telangiectatic vessels, suggestive of a retinal vasoproliferative tumor. Standardized echography showed an irregular mass with medium-to-high internal reflectivity and internal calcification, which suggested chronicity. He was initially treated for an exudative retinal detachment (RD) in the context of a presumed vasoproliferative tumor but later developed combined exudative and rhegmatogenous RD, prompting surgical repair with tumor endoresection. Pathology showed nonpigmented adenoma of the retinal pigment epithelium (RPE). Conclusions: Nonpigmented adenoma of the RPE is a rare tumor, and its clinical similarity to a vasoproliferative tumor should be noted. Endoresection may be considered in cases resulting in RD.

Congenital simple hamartoma of the retinal pigment epithelium: 4 cases with multimodal imaging

BACKGROUND

Congenital simple hamartoma of the retinal pigment epithelium is often identified as an incidental finding. One important issue is the differentiation of these benign lesions from other lesions which could be potentially sight-threatening.

METHODS

This study describes 4 cases of congenital simple hamartoma of the retinal pigment epithelium that were referred to a university-based hospital. Multimodal imaging including fundus photo, multicolor fundus photo, fundus autofluorescence, optical coherence tomography (OCT), OCT angiography, fluorescein angiography and multifocal electroretinogram is provided.

RESULTS

The first case is a young man with an incidental finding of this lesion. The second and third cases are diabetic patients with congenital simple hamartoma of the retinal pigment epithelium and diabetic macular edema and the fourth one is a case of congenital simple hamartoma of the retinal pigment epithelium with a full-thickness macular hole.

CONCLUSIONS

Differentiation of congenital simple hamartoma of the retinal pigment epithelium from other potentially sight-threatening lesions is important. Multimodal imaging can be helpful regarding this issue. Besides typical findings described in the literature, unique features in our cases include concurrent diabetic macular edema and association with a full-thickness macular hole.

Ophthalmic Manifestations of Heimler Syndrome in Two Siblings With PEX1 Variants

PURPOSE

To report two new cases with confirmed diagnosis of Heimler syndrome and describe their systemic and ophthalmic phenotype and visual rehabilitation.

METHODS

Retrospective review of medical records.

RESULTS

Both siblings were diagnosed as having sensori-neural hearing loss and retinal dystrophy with exuberant intraretinal cystoid spaces and cone-rod dysfunction. The older sibling also had amelogenesis imperfecta and neither had nail abnormalities. Genetic analysis identified homozygosity for the pathogenic variant c.2528G>A p.(Gly843Asp) in the PEX1 gene in both siblings. The parents were heterozygous carriers of the variant.

CONCLUSIONS

The authors report a familial case of Heimler syndrome due to biallelic PEX1 pathogenic variants that manifested as macular dystrophy characterized by cone-rod dysfunction and complicated by intraretinal cystoid spaces. Review of the literature shows that ocular phenotype is variable in patients with Heimler syndrome. [J Pediatr Ophthalmol Strabismus. 2024;61(1):59-66.].

[Retinal tumors in adults: Part 2 nonvascular tumors of retina and retinal pigment epithelium]

Retinal tumors are a heterogeneous group of congenital and acquired lesions. In the second part of the article retinocytic and glial cell tumors of the retina, tumors of the retinal pigment epithelium, malignant tumors, such as lymphomas and metastases are presented. In benign and malignant tumors visual symptoms, such as exudative retinal detachment occur, which often lead to irreversible visual impairments. Because visual symptoms are often a manifestation of systemic diseases, the ophthalmologist plays an important role in the accurate and early diagnosis of retinal tumors. This article reviews the most important clinical and diagnostic features of retinal tumors in adults, the systemic associations and the literature on currently available treatment strategies.

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.

An unusual presentation of macular telangiectasia type 2 with a large pigment deposit

Macular telangiectasia type 2 (MacTel) is a bilateral retinal disease that seems to be limited to the juxtafoveal region of the macula. We herein report an unusual presentation of MacTel with a large pigment deposit at the macula. Fundus of the right eye showed a large pigment deposit at the macula and right-angled venule. The left eye fundus showed a grayish discoloration due to subretinal fibrosis, dark pigment clumps and right-angled venule in the macula. Lesions were highlighted on multicolor imaging and blue reflectance imaging. Spectral domain optical coherence tomography (SD-OCT) of both eyes showed hyperreflectivity on the inner aspect of the retina corresponding to the area of pigment clumping.

Retinal Pigment Epithelium Adenoma and Adenocarcinoma: A Review

Adenoma and adenocarcinoma of the retinal pigment epithelium (RPE) are rare intraocular tumours that are often misdiagnosed as posterior uveal melanoma or other simulating lesions. It is important to be able to differentiate these tumours from melanoma for 3 reasons. First, an inability to rule out melanoma often tilts the management towards enucleation. Second, management options like radiotherapy and local resection which work well for melanoma may not be easily applied to these tumours. Third, and most importantly, patients with melanoma need a lifetime follow-up to rule out metastases (metastatic dormancy) whereas RPE tumours hardly metastasize. An abruptly elevated, often deeply pigmented tumour, with a prominent retinal feeding artery and a draining vein causing exudation, should raise a suspicion of RPE tumours. RPE tumours have a remarkable local invasive potential but a low metastatic potential. Most RPE tumours require treatment due to local complications. Small, asymptomatic tumours can be generally observed. Enucleation is still the gold standard of treatment, although local resection has been reported in selected cases with good results. Here, we provide a comprehensive review of the demographic, clinical, and imaging features of true acquired neoplasms of the RPE, namely adenoma and adenocarcinoma, the ways to differentiate them from melanoma, their clinical course and prognosis, and Options for their management.

From an asymptomatic lesion to a vision-threatening condition: Congenital hypertrophy of the retinal pigment epithelium complicated by choroidal neovascular membrane

We reported a case of congenital hypertrophy of the retinal pigment epithelium (CHRPE) complicated by choroidal neovascular membrane (CNVM). A 41-year-old woman presented to our clinic with visual loss in the left eye. She was diagnosed as CHRPE complicated by a CNVM. The patient was treated with 2 consecutive monthly intravitreal aflibercept (IVA) injections. The best-corrected visual acuity (BCVA) improved and stabilized at 6/6. Subretinal fluid depending on CNVM resolved completely. CHRPE complicated by CNVM in the macular area is a rare condition and these cases can be treated with IVA therapy.

Treatment Outcome of Acquired Retinal Pigment Epithelial Tumors with Rhuthenium-106 Plaque Radiotherapy: Experience on Two Cases

Purpose:

To report the clinical outcome of rhuthenium-106 plaque radiotherapy in acquired retinal pigment epithelial (RPE) tumors.

Methods:

In this interventional case series, two eyes of two patients with clinically diagnosed ocular-acquired RPE tumors including adenoma and adenocarcinoma underwent plaque radiotherapy with rhuthenium-106. The clinical findings and visual outcome of the patients were evaluated.

Results:

The first patient was a 44-year-old male, and the second was a 32-year-old female. The follow-up times were 24 and 32 months. The tumor was unilateral and hyperpigmented in both cases, located at juxtapapillary in one patient and on peripheral part of the retina in the other. Vitreous hemorrhage and peripheral exudation were obvious in one patient. Macular edema, epiretinal membrane, and retinal feeder vessels were also detected in the examination. The patients underwent plaque radiotherapy with rhuthenium-106 as the first step of management. The tumor has been stable until the last follow-up in both patients with globe preservation and acceptable visual acuity (5/10 for the first case and 4/10 for the second case).

Conclusion:

Rhuthenium-106 plaque radiotherapy might be a conservative therapy in the management of acquired RPE tumors and prevent early enucleation.

Foveal Congenital Simple Hamartoma of Retinal Pigment Epithelium: A Report of Two Cases

We report two cases with foveal congenital simple hamartoma of the retinal pigment epithelium (CSHRPE), as both patients presented to our retina services complaining of a unilateral decreased vision. Full ophthalmic examination and multimodal imaging were performed including fundus photography, fundus autofluorescence, optical coherence tomography, fluorescein angiography, and electrophysiological testing. Both patients presented with 20/80 vision in the affected eyes. Foveal CSHRPE was found in both eyes, along with parapapillary hyperpigmented rim, multiple pinpoint macular lesions, and few posterior pole hyperpigmented lesions. Multifocal electroretinogram showed diminished central amplitude in both eyes, with three-dimensional topography map showing blunted foveal peaks in one eye and the absence of a central peak in the other patient. Both patients had a stable vision and clinical examination of the CSHRPE during 5 and 6 years follow up, respectively. Foveal CSHRPE is usually symptomatic and results in a decline in visual acuity. Follow-up of these patients showed stable vision and clinical examination.

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.

Retinal sensitivity and photoreceptor arrangement changes secondary to congenital simple hamartoma of retinal pigment epithelium

Background

The congenital simple hamartoma of the retinal pigment epithelium is a benign lesion and previous observations with noninvasive imaging have detected potential photoreceptor abnormalities and retinal function interplay.

Case presentation

A 35-year-old woman was found to have an asymptomatic, solitary, circumscribed, pigmented lesion in her left eye. The patient underwent ophthalmic examination including multimodal evaluation with fluorescein angiography, near-infrared reflectance scanning laser ophthalmoscopy, blue autofluorescence, enhanced-depth imaging spectralis B-scan optical coherence tomography (EDI-SBOCT), en face OCT angiography (OCT-A) and microperimetry plus adaptive optics imaging. Ophthalmoscopic examination revealed a juxtafoveolar pigmented lesion with feeding retinal arteriole, consistent with congenital simple hamartoma of RPE. There was no macular edema, exudation, hemorrhage, traction or subretinal fluid. Multimodal imaging of the mass using fluorescein angiography revealed intra-lesion late staining, near-infrared reflectance imaging demonstrated intrinsic hyperreflectivity, short-wavelength autofluorescence and red-free filter photography revealed blocked signal, and SBOCT showed abrupt shadowing. On OCT-A, an exclusive ring-shaped vascular circuit with increased foveal avascular zone was noted. Adaptive optics revealed cell density arrangement and retinal sensitivity correlations on microperimetry.

Conclusion

These findings suggest that this hamartomatous lesion might cause specific cellular changes that impact retinal sensitivity response and potentially result from vasculature malnourishment to the outer retinal layers.

[New treatment options for iridociliary tumors]

BACKGROUND

Benign iridal tumors rarely necessitate a therapeutic intervention. In contrast, malignant tumors of the iris can threaten the patient's life and eyesight and require early treatment to prevent the development of metastases.

OBJECTIVE

Presentation of current treatment options for iridal tumors with special emphasis on iridal melanoma.

METHODS

This article gives an overview of the current literature based on a PubMed search as well as own clinical experience.

RESULTS

Treatment options for iridal and ciliary body melanomas comprise radiotherapeutic and surgical (eyeball-sparing and non-sparing) approaches. The eyeball-sparing surgical procedure of choice is block excision. While local tumor control rates and metastasis rates of block excision and radiotherapy are comparable, there are distinct differences especially between the spectra of complications. New treatment procedures include immunomodulatory approaches and targeted therapies. Using checkpoint inhibitors, no convincing enhancement of overall survival could be demonstrated for metastatic iridal melanoma, as is the case for cutaneous melanoma. In contrast, tumor vaccination with the help of tumor RNA-laden patient-derived dendritic cells seems to be a promising option for a subgroup of high-risk patients. Targeted therapies aiming to suppress the MAPK and PI3K/Akt pathways could not achieve any improvement in patient survival.

CONCLUSION

For the primary treatment of iridal melanoma a surgical, eyeball-sparing approach and also when appropriate, radiotherapy can be recommended. In the future, eligible high-risk patients could profit from a tumor vaccination. To date, there is no effective systemic treatment for metastatic iridal melanoma.