Peripapillary hyper-reflective ovoid mass-like structures (PHOMS): clinical significance, associations, and prognostic implications in ophthalmic conditions

Application of novel non-invasive ophthalmic imaging to visualize peripapillary wrinkles, retinal folds and peripapillary hyperreflective ovoid mass-like structures associated with elevated intracranial pressure

Background

Elevated intracranial pressure (ICP) is a serious and potentially life-threatening condition, for which clinically useful non-invasive measures have been elusive, in some cases due to their inadequate sensitivity and specificity. Our aim was to evaluate novel non-invasive ophthalmic imaging of selected pathological features seen in elevated ICP, namely peripapillary hyperreflective ovoid mass-like structures (PHOMS), peripapillary wrinkles (PPW) and retinal folds (RF) as potential biomarkers of elevated ICP.

Methods

This single-center pilot study included subjects with untreated or incompletely treated high ICP. The retinas of these subjects were evaluated with averaged en-face optical coherence tomography (OCT), OCT retinal cross-sections (OCT B-scans), adaptive optics scanning light ophthalmoscopy (AOSLO), and fundus photos.

Results

Seven subjects were included in the study. 6 subjects with high ICP (5 idiopathic intracranial hypertension, 1 medication induced, 30.8 ± 8.6 years, 75% female, 5 with papilledema) and 1 control (20-25 years) were included. PHOMS, PPW and RF were present in all subjects with papilledema, but neither in the high ICP subject without papilledema nor in the control subject. Averaged en-face OCT scans and AOSLO were more sensitive for PPW and RF than OCT B-scans and commercial fundus photos.

Conclusion

PPW, RF and PHOMS volume have potential as non-invasive biomarkers of ICP. Novel imaging modalities may improve sensitivity. However, lack of automated image acquisition and processing limits current widespread adoption in clinical settings. Further research is needed to validate these structures as biomarkers for elevated ICP and improve clinical utility.

Peripapillary hyperreflective ovoid mass-like structures with cystoid macular edema: a case report

BACKGROUND

Peripapillary hyperreflective ovoid mass-like structures (PHOMS) are newly characterized lesions wedged around the optic discs, which used to be misdiagnosed. Better understanding and identifying PHOMS are important for monitoring the condition of optic nerve.

CASE PRESENTATION

A young female presented to the ophthalmic clinic with blurred vision of both eyes. Protrusions resembling "C-shaped donut" were found circling the optic discs bilaterally. These lesions were homogenous hyperreflective on OCT, while they were also hypoautofluorescent and hypoechogenic. Meanwhile, cystoid macular edema (CME) was also identified in both eyes. The patient was then diagnosed as PHOMS with CME. A short-term glucocorticoids therapy was prescribed systemically. The logMAR best-corrected visual acuity (BCVA) of both eyes reached 0.0 in 4 months with recovery of CME, while the PHOMS remained.

CONCLUSIONS

There is currently no report on PHOMS with CME. More attentions should be paid to PHOMS, for they are potential biomarkers for axoplasmic stasis involved in different diseases of the optic nerve.

Case Report: Optic Disc Melanocytoma with PHOMS-Minimum Intensity Projection Image

Introduction

Optic disc melanocytoma (ODMC) with peripapillary hyperreflective ovoid mass-like structures (PHOMS) is rare. This study reports a case of the characteristics of multimodal imaging and Minimum intensity projection (Min-IP) images.

Methods

A 25-year-old male patient was referred to our hospital due to the presence of a dark pigmented tumor located in the optic disc area of his left eye. The patient exhibited normal pupillary reactions and had a best corrected visual acuity of 1.0 (decimal) in both eyes. This patient underwent multimodal retinal imaging examination including color fundus photograph (CFP), B-scan ultrasonography, Fundus autofluorescence (FAF), SD-OCT (spectral-domain optical coherence tomography), OCTA (optical coherence tomography angiography), en-face Min-IP image and fluorescein angiography (FA).

Results

CFP revealed a slightly elevated mass lesion in the inferior quadrant of the left optic disc, the lesion appeared black to dark brown in color. B-scan ultrasonography of the left eye confirmed the presence of a hyperechoic small dome-shaped lesion. Fundus autofluorescence (FAF) analysis revealed complete hypofluorescence in this area. SD-OCT (spectral-domain optical coherence tomography) and OCTA (optical coherence tomography angiography) with Min-IP were performed over the tumor and its surrounding areas. SD-OCT showed an elevated tumor mass arising from the optic disc with increased reflectivity. PHOMS appeared ovoid in shape on B-scan OCT image. PHOMS appeared peripapillary hyperreflective bright areas on en-face Min-IP image corresponding to PHOMS on B-scan OCT image. The fluorescein angiography (FA) showed the staining of PHOMS. A diagnosis of optic disc melanocytoma with PHOMS was established prompting the patient to be advised for regular follow-up.

Conclusion

The optic disc melanocytoma with PHOMS is a rare benign ocular lesion that requires minimal active intervention, but demands a lifetime follow-up. The multimodal imaging and Min-IP images have clinical diagnostic value.

Optic neuropathy in craniosynostosis

Craniosynostosis (CS) or the premature fusion of one or more cranial sutures in utero, or during the first years of life, can present in isolation or as a multisystem clinical disorder with a particular impact on visual function. Among ophthalmic complications, optic neuropathy is a significant cause of irreversible vision loss in these patients. Children with CS are at higher risk of developing elevated intracranial pressure which can lead to papilledema and, ultimately, optic atrophy. In addition, sometimes associated obstructive sleep apnea, abnormalities in central nervous system venous development, and Chiari malformation may contribute to optic neuropathy. Ophthalmologists have an important role in managing a number of coexistent ophthalmologic complications such as strabismus, anisometropia, amblyopia, ptosis, and exposure keratopathy in addition to maintaining surveillance for early signs of optic neuropathy; they play a critical consultative role contributing to the decision for primary or repeat decompressive surgery. In this article, we aim to review the etiology, diagnostic approach, and management of optic neuropathies in patients with craniosynostosis.