Review of spectral domain-enhanced depth imaging optical coherence tomography of tumors of the retina and retinal pigment epithelium in children and adults

Advances in multimodal imaging for diagnosis of pigmented ocular fundus lesions

Pigmented ocular fundus lesions can range from benign to malignant. While observation is reasonable for asymptomatic benign lesions, early recognition of tumours that are vision or life threatening is critical for long-term prognosis. With recent advances and increased accessibility of multimodal imaging, it is important that providers understand how to best use these tools to detect tumours that require early referral to subspecialty centres. This review aims to provide an overview of pigmented ocular fundus lesions and their defining characteristics using multimodal imaging. We cover the spectrum of pigmented ocular fundus lesions, including freckle and focal aggregates of normal or near-normal uveal melanocytes, retinal pigment epithelium (RPE) hyperplasia, congenital hypertrophy of the RPE, RPE hamartoma associated with familial adenomatous polyposis, congenital simple hamartoma of the RPE, combined hamartoma of the retina and RPE (congenital hypertrophy of the RPE), choroidal nevus, melanocytosis, melanocytoma, melanoma, adenoma, and RPE adenocarcinoma. We describe key diagnostic features using multimodal imaging modalities of ultra-widefield fundus photography, fundus autofluorescence, optical coherence tomography (OCT), enhanced-depth imaging OCT, ultrasonography, fluorescein angiography, indocyanine green angiography, and OCT angiography (OCTA), with particular attention to diagnostic features that could be missed on fundus examination alone. Finally, we review what is on the horizon, including applications of artificial intelligence. Through skilled application of current and emerging imaging technologies, earlier detection of sight- and life-threatening melanocytic ocular fundus tumours can lead to improved patient prognosis.

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.

Optical Coherence Tomography and Optical Coherence Tomography Angiography in Pediatric Retinal Diseases

Indirect ophthalmoscopy and handheld retinal imaging are the most common and traditional modalities for the evaluation and documentation of the pediatric fundus, especially for pre-verbal children. Optical coherence tomography (OCT) allows for in vivo visualization that resembles histology, and optical coherence tomography angiography (OCTA) allows for non-invasive depth-resolved imaging of the retinal vasculature. Both OCT and OCTA were extensively used and studied in adults, but not in children. The advent of prototype handheld OCT and OCTA have allowed for detailed imaging in younger infants and even neonates in the neonatal care intensive unit with retinopathy of prematurity (ROP). In this review, we discuss the use of OCTA and OCTA in various pediatric retinal diseases, including ROP, familial exudative vitreoretinopathy (FEVR), Coats disease and other less common diseases. For example, handheld portable OCT was shown to detect subclinical macular edema and incomplete foveal development in ROP, as well as subretinal exudation and fibrosis in Coats disease. Some challenges in the pediatric age group include the lack of a normative database and the difficulty in image registration for longitudinal comparison. We believe that technological improvements in the use of OCT and OCTA will improve our understanding and care of pediatric retina patients in the future.

Metastatic tumours to the eye. Review of metastasis to the iris, ciliary body, choroid, retina, optic disc, vitreous, and/or lens capsule

Metastasis to the eye can involve the choroid (90%), ciliary body (2%), iris (8%), and retina, optic disc, vitreous, and/or lens capsule (<1-4%). The mean number of uveal metastasis per eye (1.7), mean tumour base (11.6 mm) and thickness (3.2 mm), tumour colour (86% yellow), and presence of subretinal fluid (72%), are all clinical features suggestive of the diagnosis. Imaging with ultrasonography demonstrates an echodense mass (80%) and optical coherence tomography shows a "lumpy bumpy" choroidal surface (64%), both important diagnostic features. Uveal metastases typically emanate from primary cancer of the breast (37%), lung (27%), kidney (4%), gastrointestinal tract (4%), cutaneous melanoma (2%), lung carcinoid (2%), prostate (2%), thyroid (1%), pancreas (1%), and other sites (3%). Occasionally, fine needle aspiration biopsy is employed if the primary site is not known. In 16% of cases, the primary site remains unknown. Rarely, metastases affect the retina, vitreous, and lens capsule, most often originating from cutaneous melanoma and in patients previously treated with checkpoint inhibitor therapy. Kaplan-Meier analysis in a series of 1111 patients with uveal metastasis revealed 32% survival at 3 years and 24% at 5 years. Patients with uveal metastasis from carcinoid tumour showed most favourable survival at 5-years (92%), whereas pancreatic and kidney cancer demonstrated least favourable survival (0%). The 5-year survival was better for females (versus (vs.) males) (31% vs. 21%) and older adults (vs. children) (40% vs. 0%). In this review, we examine several large-cohort publications on the topic of ocular metastasis.

Benign Lobular Inner Nuclear Layer Proliferations of the Retina Associated with Congenital Hypertrophy of the Retinal Pigment Epithelium

PURPOSE

To report the clinical and imaging findings of 4 patients with benign intraretinal tumors, 2 of which were associated with retinal pigment epithelium (RPE) hypertrophy. To our knowledge, this condition has not been described previously and should be distinguished from retinoblastoma and other malignant retinal neoplasms.

DESIGN

Retrospective case series.

PARTICIPANTS

Four patients from 3 institutions.

METHODS

Four patients with intraretinal tumors of the inner nuclear layer (INL) underwent a combination of ophthalmic examination, fundus photography, fluorescein angiography, OCT, OCT angiography, and whole exome sequencing.

MAIN OUTCOME MEASURES

Description of multimodal imaging findings and systemic findings from 4 patients with benign intraretinal tumors and whole exome studies from 3 patients.

RESULTS

Six eyes of 4 patients 5, 13, 32, and 27 years of age were found to have white intraretinal tumors that remained stable over the follow-up period (range, 9 months-4 years). The tumors were unilateral in 2 patients and bilateral in 2 patients. The tumors were white, centered on the posterior pole, and multifocal, with some consisting of multiple lobules with arching extensions that extended beyond the central tumor mass. OCT demonstrated these lesions to be centered within the INL at the border of the inner plexiform layer. In addition, 2 patients demonstrated congenital hypertrophy of the RPE (CHRPE) lesions. Three of 4 patients underwent whole exome sequencing of the blood that revealed no candidate variants that plausibly could account for the phenotype.

CONCLUSIONS

We characterize a novel benign tumor of the INL that, in 2 patients, was associated with separate CHRPE lesions. We propose the term benign lobular inner nuclear layer proliferation to describe these lesions.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found after the references.

Hamartomas of the Retina and Optic Disc

Hamartomas are local malformation of cells that demonstrate abnormal proliferation in the area where they are normally present. Retinal and optic disc hamartomas include astrocytic hamartoma, congenital hypertrophy of the retinal pigment epithelium (CHRPE), simple congenital hamartoma of the retinal pigment epithelium (CSHRPE), combined hamartoma of the retina and retinal pigment epithelium (CHRRPE), retinal hemangioblastoma (retinal capillary hemangioma), and retinal cavernous hemangioma. Retinal and optic disc hamartomas can be observed sporadically as well as with systemic associations. Astrocytic hamartoma usually appears as a flat, transparent yellowish lesion. CHRPE is a round, pigmented, and flat lesion. CSHRPE usually presents as a dark black macular tumor. CHRRPE consists of vascular, glial, and pigment epithelial components, which can demonstrate peripapillary, macular, and peripheral localization. Retinal hemangioblastoma is a vascular tumor, red-pink in color with tortuous and dilated afferent and efferent vessels, typically located in the peripheral retina or optic disc. Retinal cavernous hemangioma is characterized by the formation of thin-walled saccular angiomatous structures in the retina or optic nerve head resembling concord grapes. Ultrasonography, fundus autofluorescence, optical coherence tomography, optical coherence tomography angiography, and fluorescein angiography methods are used in the diagnosis of retinal and optic disc hamartomas. Some retinal and optic disc hamartomas do not require treatment. However, complications including vitreous hemorrhage, macular exudation, retinal detachment, macular hole, epiretinal membrane, and choroidal neovascularization require treatment.

Retinal hemangioblastoma in a patient with Von Hippel-Lindau disease: A case report and literature review

BACKGROUND

Retinal hemangioblastoma (RH) is a rare benign tumor and a considerable number of which are caused by Von Hippel-Lindau disease (VHL). Herein, we described a case of VHL-associated RH with retinal detachment who underwent both laser photocoagulation and vitreoretinal surgery and received satisfactory visual recovery. In addition, we reviewed the current diagnosis, genotype-phenotype association, and treatment of VHL-associated RH.

CASE DESCRIPTION

A 34-year-old woman presented with vision loss in the right eye at our hospital. Fundus photography and angiography showed retinal detachment and multiple large hemangiomas in the right eye. The visual acuity improved significantly after laser photocoagulation and vitreoretinal surgery. Genetic analyses showed a p.Asn78Ser (c.233A>G) heterozygous missense mutation in the VHL gene.

CONCLUSION

We described a rare case of VHL-associated RH and may provide a new perspective towards diagnosis and treatment of this disease. RH is one of the most common manifestations of VHL and poses a serious threat to vision. Ophthalmic examination methods include fundus examination and fundus photography, etc. The management of the disease emphasizes timely follow-up, early detection of the lesion, and the decision of treatment options according to the size, location and complications of the lesion, including ablation therapy and vitreoretinal surgery. Clinicians should strengthen the understanding of this rare disease for early detection and treatment.

The Role of Optical Coherence Tomography and Optical Coherence Tomography Angiography in the Differential Diagnosis of Posterior Uveitis

PURPOSE

Modalities such as optical coherence tomography (OCT) and OCT angiography (OCTA) have improved the diagnostic utility of fundus imaging in management of uveitis. The purpose of this study is to review role of OCT and OCTA in differential diagnosis of certain posterior uveitic entities.

METHODS

Narrative review.

RESULTS

In this review, we have comprehensively summarized the utility of OCT and OCTA in helping the clinician diagnose common but challenging inflammatory conditions including ocular toxoplasmosis, viral retinitis, and vitreoretinal lymphoma, among others. OCT and OCTA can also be used to assess the choriocapillaris involvement in conditions such as multiple evanescent white dot syndrome, and choroidal granulomas in tubercular and sarcoid uveitis.

CONCLUSIONS

Fundus imaging with OCT and OCTA has assumed a significant role in establishing the diagnosis in uveitis apart from microbiological and other laboratory analysis. Advantages such as rapidity and non-invasiveness make these imaging modalities very useful and convenient.

Structural Abnormalities of the Central Retina in Neurofibromatosis Type 2

INTRODUCTION

This case-control study seeks to systematically characterize the central retinal findings in a large cohort of patients with neurofibromatosis type 2 (NF2) using spectral domain optical coherence tomography (SD-OCT) as well as the examination of the potential use of this technique as a diagnostic tool in NF2.

METHODS

Fifty-four patients with an NF2 diagnosis seen in a quaternary national service were age- and gender-matched to 55 controls from the normal population. Two masked assessors categorized SD-OCT images using predefined abnormalities: retinal tufts, epiretinal membrane (ERM) appearance, retinal hamartoma, and foveal contour. Specificity, sensitivity, and positive and negative predictive values were calculated for each retinal abnormality. Trends of retinal abnormalities with NF2 genetic severity groups (1. tissue mosaic; 2A. mild classic; 2B. moderate classic; and 3. severe) were investigated.

RESULTS

We found retinal abnormalities in 26 patients with NF2 (48%) and 2 control patients (4%); retinal tufts were the most common abnormality therein (43%) and were not seen in controls. The specificity and sensitivity of the graded abnormalities on OCT scans in NF2 were 96% and 48%, respectively, with a positive predictive value of 93%. In our cohort, retinal tufts had a specificity of 100%, a sensitivity of 43%, and a positive predictive value of 100%. Retinal hamartomas were seen only in NF2 patients (35% sensitivity and 100% specificity). ERMs had 96% specificity and 13% sensitivity. The proportion of patients with retinal abnormalities increased statistically significantly with NF2 genetic severity; all patients within the 3. severe genetic severity had an abnormal SD-OCT.

DISCUSSION/CONCLUSION

We present a systematic study of central retinal abnormalities in an NF2 population as seen on SD-OCT imaging. Our results show a high frequency of retinal abnormalities that are readily detected by SD-OCT imaging. The presence of retinal tufts may be a novel marker of NF2 with both high specificity and a positive predictive value for NF2, compared to other well-known ocular features of NF2, and may have a place in the NF2 diagnostic criteria.

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.

Optical Coherence Tomography Characteristics of the Choroid Underlying Congenital Hypertrophy of the Retinal Pigment Epithelium

Purpose

This study evaluates and characterizes the choroid underlying congenital hypertrophy of the retinal pigment epithelium (CHRPE).

Methods

Retrospective observational study of CHRPE at least 2 mm in diameter. Choroidal vascular architecture was qualitatively examined. Choroidal thickness was measured by 2 independent observers using enhanced depth imaging spectral domain optical coherence tomography.

Results

Forty-six eyes of 46 patients with CHRPE were included. Thirty-two lesions had imaging sufficient for analysis. Haller's layer was healthy in 18 (56%), thin in 13 (41%), and absent in 1 (2%). Sattler's layer was atrophic in 30 (94%), and choriocapillaris was atrophic in 31 (97%). CHRPE with thinned Haller's layer had significantly larger diameter. The mean sub-CHRPE choroidal thickness was 82.4 ± 7.9 µm, compared to a thickness of 148.4 ± 9.6 µm in the normal adjacent choroid (p < 0.0001). Mean retinal thickness overlying the CHRPE was 77.3 ± 4.3 µm, compared to a retinal thickness of 137.8 ± 2.9 µm overlying the normal adjacent choroid (p < 0.0001). Sub-CHRPE choroidal thickness was a mean of 56.2 ± 3.1% of the adjacent normal choroidal thickness.

Conclusion

The underlying choroid CHRPE is thinner than the adjacent normal choroid. All layers of the choroid can be thin with a preference of the inner Sattler's and choriocapillaris layers.

VON HIPPEL-LINDAU DISEASE: Update on Pathogenesis and Systemic Aspects

PURPOSE

To provide an update summarizing the biologic pathways governing von Hippel-Lindau (VHL) disease pathogenesis and to provide an overview of systemic manifestations as well as screening recommendations.

METHODS

A PubMed search of the English language literature was reviewed using the following search terms: von Hippel-Lindau, von Hippel-Lindau disease, and VHL. Of 6,696 publications, the most current and pertinent information related to the pathogenesis and systemic aspects of VHL disease were included in this review.

RESULTS

von Hippel-Lindau disease is one of the most frequently occurring multisystem familial cancer syndromes. The disease results from germline mutation in the VHL tumor suppressor gene on the short arm of chromosome 3. Mutation in the VHL gene affects multiple cellular processes including transcriptional regulation, extracellular matrix formation, apoptosis, and, in particular, the cellular adaptive response to hypoxia. As a result, there is widespread development of vascular tumors affecting the retina, brain, and spine, as well as a spectrum of benign and malignant tumors and/or cysts in visceral organs.

CONCLUSION

The ophthalmologist plays a key role in VHL disease diagnosis, as retinal hemangioblastoma is frequently the first disease manifestation. Screening guidelines for individuals with known VHL disease, and those at risk of VHL disease, help to ensure early detection of potentially vision-threatening and life-threatening disease.

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.

The Role of Optical Coherence Tomography Angiography in Ranibizumab-Treated Choroidal Neovascularization in Choroidal Osteoma

In this study, we report the initial evaluation of choroidal neovascularization (CNV) secondary to choroidal osteoma and subsequent response to anti-vascular endothelial growth factor (anti-VEGF) treatment monitored with optical coherence tomography angiography (OCT-A). A 38-year-old female presented with an initial visual acuity of 20/150 in the left eye. Clinical examination revealed a choroidal osteoma. OCT demonstrated both subretinal and intraretinal fluid. OCT-A was performed and showed CNV. A course of ten treatments with ranibizumab showed an improvement of visual acuity to 20/30–3, improvement of subretinal and intraretinal fluid, as well as attenuation of CNV. Our report demonstrates OCT-A as a useful tool for both initial evaluation of CNV and following treatment response to anti-VEGF therapy.

Swept-source optical coherence tomography features of regressed macular retinoblastoma

Purpose:

To describe the swept-source optical coherence tomography (SS-OCT) features of regressed macular retinoblastoma (RB).

Methods:

A cross-sectional observational study was carried out in 13 patients with regressed macular RB with good fixation in at least one eye. Fundus photography and SS-OCT were documented. High-resolution scans with good signal strength were selected. The types of clinical regression and SS-OCT characteristics of the regressed lesions (presence of vitreous detachment, intratumor schisis/cavitation, calcification, foveal dip, and OCT pattern) were noted.

Results:

Of the 13 eyes, 7 (53%) were group B, 4 (30%) were group C, and 2 (17%) were group D. Lesion involving fovea was seen in seven eyes (53%). On SS-OCT, the lesion was isodense to hyperdense in all cases. Three patterns of regressed RB were noted on OCT. Intralesion calcification was noted in eight cases. Subretinal fluid was not detected in any of the cases.

Conclusion:

SS-OCT is a useful technology to image and analyze cases of regressed macular RB including large lesions. SS-OCT system helps in successful imaging even in smaller children.

Adenoma and Adenocarcinoma of the Retinal Pigment Epithelium: A Review of 51 Consecutive Patients

PURPOSE

To describe the clinical and imaging characteristics, pathologic features, and management options of retinal pigment epithelium (RPE) adenoma/adenocarcinoma.

DESIGN

Retrospective case series.

PARTICIPANTS

Fifty-one patients with RPE adenoma/adenocarcinoma.

METHODS

Treatment options for the patients included observation, partial lamellar sclerouvectomy (PLSU), enucleation, and others.

MAIN OUTCOME MEASURES

Factors related to visual acuity (VA) outcomes (>2 Snellen lines loss, poor final VA [≤20/200], good final vision [≥20/40]), tumor growth, and need for enucleation.

RESULTS

The mean patient age at diagnosis was 51 years, and the majority of patients were white (40/51, 78%) and female (34/51, 67%). Primary management included observation (29/51, 57%), PLSU (9/51, 18%), enucleation (4/51, 8%), or others (9/51, 18%). Outcomes revealed decreased VA (10/32, 31%), poor final VA (17/32, 53%), good final VA (11/32, 34%), tumor growth (12/25, 48%), and need for enucleation (7/51, 14%). By multivariable analysis, features predictive of decreased VA included increasing baseline tumor thickness (P = 0.01) and presence of vitreous hemorrhage (P = 0.05). Factors predictive of poor final VA included presence of exudative retinal detachment (P = 0.004), baseline VA 20/50 to 20/150 (P = 0.008), and baseline VA ≤20/200 (P = 0.01). Absence of feeding and/or draining vessel was predictive of good VA (P = 0.004). Tumor growth was associated with multiple treatments (P = 0.02). Increased tumor thickness (P = 0.03) and presence of exudative retinal detachment (P = 0.01) were predictive of enucleation.

CONCLUSION

RPE adenoma/adenocarcinoma can simulate choroidal melanoma. Greater tumor thickness, vitreous hemorrhage, exudative retinal detachment, and poor baseline VA predict worse visual outcome and greater risk for enucleation.

Optical coherence tomography (OCT) to image active and inactive retinoblastomas as well as retinomas

PURPOSE

To illustrate Optical Coherence Tomography (OCT) images of active and inactive retinoblastoma (Rb) tumours.

METHODS

Current observational study included patients diagnosed with retinoblastoma and retinoma who were presented at Amsterdam UMC and Jules-Gonin Eye Hospital, between November 2010 and October 2017. Patients aged between 0 and 4 years were imaged under general anaesthesia with handheld OCT in supine position. Patients older than 4 years were imaged with the conventional OCT (Heidelberg Engineering, Heidelberg Spectralis, Germany). All patients included were divided into two groups: active and inactive tumours (retinoma and regression patterns). Patients' medical records and OCT images were analysed during meetings via discussions by ophthalmologists and physicists.

RESULTS

Twelve Dutch and 8 Swiss patients were divided into two groups: 2 patients with active tumour versus 18 patients with inactive tumour. Subsequently, inactive group could be divided in two groups, which consisted of 10 patients with retinoma and 8 patients with different regression pattern types. Of all included patients, 15 were male (75%). Median age at diagnosis was 18.0 months (range 0.19-715.2 months). A total of 12 retinoblastoma (active and inactive) and 8 retinoma foci were investigated by OCT. No distinction could be made between active and inactive tumours using only OCT.

CONCLUSION

Optical coherence tomography alone cannot distinguish between active and inactive Rbs. However, handheld OCT adds useful information to the established imaging techniques in the monitoring and follow-up of retinoblastoma patients. With this study, we provide an overview of OCT images of active and inactive Rbs.

Optical coherence tomography in pediatric patients: a clinical review

Optical coherence tomography has improved the ophthalmic clinical examination due to its ability to more accurately characterize pathology of the eye. Optical coherence tomography is now an integral imaging modality for many adult diseases of the retina and is a ubiquitous part of a retinal practice. However, although its use in adults is well recognized, the adoption of optical coherence tomography in pediatric patients may be undervalued as macular diseases in children are relatively uncommon. Recent technological advancements have made optical coherence tomography scans quicker and more precise, generating normative data and leading to more widespread use in children. In this review article, we discuss how pediatric optical coherence tomography data can be used to understand normal development, as well as diagnose and monitor retinal disease. In particular, we highlight clinical optical coherence tomography findings of several pediatric retinal conditions, including retinopathy of prematurity, congenital infections, retinal dystrophies, and phakomatoses such as neurofibromatosis.

HAND-HELD OPTICAL COHERENCE TOMOGRAPHY MONITORING OF CHEMORESISTANT RETINOBLASTOMA

PURPOSE

Retinoblastoma (Rb) is a potentially fatal intraocular malignancy in children, and hand-held optical coherence tomography (HH-OCT) can assist in submillimeter detection and monitoring after treatment of Rb. Retinoblastoma located in the macula, or those with chemoresistance, can be among the most difficult to manage. We describe HH-OCT features in a case of chemoresistant macular Rb that eventually responded to plaque radiotherapy after failing intravenous chemotherapy and intraarterial chemotherapy.

METHODS

Observational case report.

RESULTS

A 15-month-old girl with leukocoria was found to have Group D Rb in the right eye of 6-mm thickness and macular Group B Rb in the left eye of 4-mm thickness. She was treated with 6-monthly cycles of systemic intravenous chemotherapy and focal consolidation therapies to both eyes, with tumor regression in both eyes. However, macular tumor in the left eye demonstrated subsequent recurrence, from regressed thickness of 792 μm on HH-OCT to a dome-shaped hyperreflective retinal mass of >2000 μm thickness. Three cycles of intraarterial chemotherapy were sufficient for tumor regression down to 977 μm thickness on HH-OCT. Six months later, macular tumor in the left eye recurred again to >2000 μm thickness and necessitated plaque radiotherapy using apex dose of 35 Gy over 95.25 hours. Hand-held OCT confirmed rapid tumor regression to 722 μm after plaque treatment and regression remained stable at 6-month follow-up.

CONCLUSION

Hand-held OCT was critical in assessment of Rb after failed intravenous chemotherapy and intraarterial chemotherapy and later documenting regression after plaque radiotherapy. Hand-held OCT is vital in providing cross-sectional imaging and measurements of small macular and paramacular Rbs.

Updates in imaging in ocular oncology

Innovations in ophthalmic imaging have made a profound impact on the diagnosis and treatment of ophthalmic disease. In ocular oncology, the development of optical coherence tomography with enhanced depth imaging and swept source technologies has made it possible to visualize the anatomical characteristics of retinoblastoma and uveal melanoma with a level of detail previously unobtainable on clinical exam alone. As a result, our understanding of the pathophysiology of vision loss in choroidal melanoma in particular has improved. These modalities have also helped identify fundoscopically “invisible” tumors and risk stratify pre-malignant choroidal lesions, making a strong case for their inclusion in all screening evaluations. Optical coherence tomography angiography, on the other hand, has allowed non-invasive imaging of the retinal and uveal vasculatures, providing insight into vascular changes associated with malignant transformation and vision loss following exposure to radiation. While the impact of new imaging technologies on clinical outcomes and overall survival in ocular oncology has yet to be determined, several reports cited herein offer promising results.

The link between colon cancer and congenital hypertrophy of the retinal pigment epithelium (CHRPE)

PURPOSE

Clarify the differences between Familial Adenomatous Polyposis (FAP)-associated Congenital Hypertrophy of the Retinal Epithelium (CHRPE) and benign variants with regards to lesion characteristics and associated risk.

OBSERVATIONS

An eighteen-year-old man with no past medical history was found to have multiple lesions in both eyes that were consistent with FAP-associated CHRPE. Although family history was negative for colon cancer, a colonoscopy was performed, and hundreds of polyps were found extending from the rectum to the distal colon with pathological findings of tubular adenoma. Genetic testing was consistent with a possible de novo Adenomatous Polyposis Coli (APC) mutation.

CONCLUSIONS

FAP is an autosomal dominant syndrome that causes colorectal cancer by age thirty-five in ninety-five percent of cases. There has been no established relationship between the benign variants of CHRPE and FAP, and patients with benign variants have no increased risk of colon cancer. While the lack of distinction in nomenclature and similar lesion appearance often leads to misdiagnosis and overtreatment, there are distinct ocular exam features that can provide the correct diagnosis. The exam findings that distinguish FAP-associated CHRPE lesions are (1) bilateralism, (2) occurrence in multiple quadrants, (3) pisiform shape, and (4) irregular borders. Knowing these features can be of great aid, especially in the setting of suspected de novo Familial Adenomatous Polyposis.

Vitreous haemorrhage a rare manifestation of retinal astrocytic hamartoma: a paediatric case report

INTRODUCTION

Retinal astrocytic hamartoma is generally an asymptomatic benign tumour that may or may not be associated with the tuberous sclerosis complex. Haemorrhage is a rare presentation.

CASE REPORT

The case concerns a 12-year-old patient with "a black spot" vision in the upper temporal hemifield of the right eye, who referred a similar episode 2 years ago. The anterior pole was normal in the slit lamp. A mass of translucent white-yellow peri-papillary appearance and vitreous peri-papillary haemorrhage was observed in funduscopy. The autofluorescence, fluorescence angiography, and optical coherence tomography characteristics were all compatible with retinal astrocytic hamartoma. Complementary studies (serology and X-rays) and the complete clinical examination rule out associated systemic involvement. The patient was followed-up closely until the vitreous haemorrhage was reabsorbed.

CONCLUSION

Vitreous haemorrhage is a rare complication of Retinal astrocytic hamartoma and funduscopic exploration is difficult. Systemic involvement should be ruled out.

Phase-based OCT angiography in diagnostic imaging of pediatric retinoblastoma patients: abnormal blood vessels in post-treatment regression patterns

Phase-based OCT angiography of retinoblastoma regression patterns with a novel handheld 1050 nm clinical imaging system is demonstrated for the first time in children between 0 and 4 years old under general anesthesia. Angiography is mapped at OCT resolution by flow detection at every pixel with en-face projection from the volume between nerve fiber layer and retinal pigment epithelium. We show a striking difference between blood vasculature of healthy retina, and retinoblastoma regression patterns after chemotherapy, as well as varying complexity of abnormal vasculature in regression patterns types 2, 3, and 4. We demonstrate abnormal, tortuous and prominent vasculature in type 3 regression patterns having the highest risk of tumor recurrences and a lower probability to reduction into flat scars. The ability to visualize 3-D angiography might offer new insights in understanding of retinoblastoma development and its response to therapy.

Multimodal imaging evaluation of combined hamartoma of the retina and retinal pigment epithelium

PURPOSE

Combined hamartoma of the retina and retinal pigment epithelium is a rare benign tumor characterized by a variable combination of glial, vascular, and pigmented components. The purpose of our study was to analyze the features of combined hamartoma of the retina and retinal pigment epithelium on optical coherence tomography angiography.

METHODS

Small case series of two cases of combined hamartoma of the retina and retinal pigment epithelium with macular and optic nerve involvement, evaluated with multimodal imaging including optical coherence tomography, fluorescein angiography, and optical coherence tomography angiography.

RESULTS

On optical coherence tomography, combined hamartoma of the retina and retinal pigment epithelium is characterized by disruption of the inner neurosensory retina and a variable degree of involvement of the external retina. Optical coherence tomography angiography showed diffuse alterations of the retinal vessels of the superficial and deeper layers, extended to the peripapillary area. Vessel abnormalities included increased tortuosity and caliber of vessels, vascular traction, and vessel stretching within the lesion.

CONCLUSION

Optical coherence tomography angiography allows in-depth multilayer analysis of tumor vascular network, highlighting the fine abnormalities of retinal vasculature characteristic of combined hamartoma of the retina and retinal pigment epithelium.

Functional optical coherence tomography of neurovascular coupling interactions in the retina

Quantitative evaluation of retinal neurovascular coupling is essential for a better understanding of visual function and early detection of eye diseases. However, there is no established method to monitor coherent interactions between stimulus-evoked neural activity and hemodynamic responses at high resolution. Here, we report a multimodal functional optical coherence tomography (OCT) imaging methodology to enable concurrent intrinsic optical signal (IOS) imaging of stimulus-evoked neural activity and hemodynamic responses at capillary resolution. OCT angiography guided IOS analysis was used to separate neural-IOS and hemodynamic-IOS changes in the same retinal image sequence. Frequency flicker stimuli evoked neural-IOS changes in the outer retina; that is, photoreceptor layer, first and then in the inner retina, including outer plexus layer (OPL), inner plexiform layer (IPL), and ganglion cell layer (GCL), which were followed by hemodynamic-IOS changes primarily in the inner retina; that is, OPL, IPL, and GCL. Different time courses and signal magnitudes of hemodynamic-IOS responses were observed in blood vessels with various diameters.

Hand-held Optical Coherence Tomography Monitoring of Submillimeter Retinoblastoma Treated with Indocyanine Green-enhanced Transpupillary Therapy

Over recent years, hand-held optical coherence tomography (HH-OCT) has become critical for retinoblastoma diagnosis and management. We report precise HH-OCT findings in a case of sub-millimeter retinoblastoma treated with foveal-sparing indocyanine green-enhanced transpupillary thermotherapy (ICG-TTT). A 2-month-old Caucasian female with bilateral Group B retinoblastoma showed two recurrent macular tumors in the right eye, demonstrating 88 μm and 37 μm of growth to 344 μm and 413 μm in thickness, respectively, on HH-OCT. Each was treated with additional intravenous chemotherapy and foveal-sparing ICG-TTT. Tumor regression to 154 μm and 224 μm was documented on HH-OCT and maintained on follow-up. HH-OCT is vital in confirming clinical findings and influencing management decisions in retinoblastoma. In this case, HH-OCT precisely documented submillimeter retinoblastoma recurrence and treatment response.

Optical coherence tomography: A guide to interpretation of common macular diseases

Optical coherence tomography is a quick, non invasive and reproducible imaging tool for macular lesions and has become an essential part of retina practice. This review address the common protocols for imaging the macula, basics of image interpretation, features of common macular disorders with clues to differentiate mimickers and an introduction to choroidal imaging. It includes case examples and also a practical algorithm for interpretation.

Optical coherence tomography and fundus autofluorescence findings in presumed congenital simple retinal pigment epithelium hamartoma

Aim: Presumed congenital simple retinal pigment epithelium hamartoma is a rare benign lesion of the macula that mimics congenital hypertrophy of the retinal pigment epithelium (RPE) and combined hamartoma of the retina and the RPE; newer imaging modalities can help in diagnosis. We report three patients with presumed congenital simple RPE hamartoma, and describe the enhanced-depth imaging optical coherence tomography (EDI-OCT) and fundus autofluorescence (FAF) findings.

Methods: Two patients were asymptomatic; one had an intraocular foreign body in addition to the hamartoma. All had a similar jet black, elevated lesion in the macula, sparing the fovea. EDI-OCT showed a characteristic hyperreflective layer with complete optical shadowing of the deeper layers; FAF showed pronounced hypoautofluorescence of the lesion.

Conclusion: Multimodal imaging with FAF and EDI-OCT can help to differentiate simple RPE hamartoma from similar RPE lesions, and may serve as a useful adjunct to clinical diagnosis of this rare tumor. We present the second largest series of presumed congenital simple RPE hamartoma, and – to the best of our knowledge – the first report of FAF findings of this tumor.

Atypical Retinal Pigment Epithelial Hyperplasia and Glial Proliferation Masquerading as Progressive Recurrent Retinoblastoma: A Case Report Review and Clinicopathologic Correlation

Background

Recurrences of retinoblastoma tumors, particularly scar recurrences, are a common phenomenon in the management of this cancer. Consolidative treatment with laser and cryotherapy are required for local control of disease. It is known that consolidative therapy can induce retinal pigment epithelium (RPE) hyperplasia and gliosis. Herein we report extensive RPE hyperplasia and gliosis during laser therapy for a focal scar recurrence, which presented as a progressive retinal opacification mimicking active retinoblastoma.

Method

This is a retrospective case review.

Results

A 2-month-old premature male was diagnosed with sporadic bilateral retinoblastoma (International Intraocular Retinoblastoma Classification [IIRC] group B in the right eye and IIRC group A in the left eye). The patient underwent laser therapy for a focal recurrence which demonstrated a white lesion during therapy and was subsequently enucleated. While there was a focal recurrence and infiltration of the retina (seen both on optical coherence tomography and histopathologic section), the majority of the white, progressive lesion was from extensive RPE hyperplasia and gliosis secondary to laser therapy.

Conclusion

Clinicopathologic correlation of the active recurrence and adjacent gliosis is demonstrated.

Combined Hamartoma of the Retina and Retinal Pigment Epithelium: An Optical Coherence Tomography-Based Reappraisal

PURPOSE

To analyze the optical coherence tomography (OCT) characteristics of combined hamartoma of the retina and retinal pigment epithelium (CHRRPE) involving the macula.

DESIGN

Retrospective, observational case series.

METHODS

setting: Single institutional.

STUDY POPULATION

Fourteen consecutive patients of CHRRPE were included.

OBSERVATION PROCEDURES

The authors analyzed the clinical features, color fundus photography, and swept-source or spectral-domain OCT of all the involved eyes.

MAIN OUTCOME MEASURES

OCT characteristics, especially the involvement of the retinal pigment epithelium (RPE).

RESULTS

A total of 16 eyes of 5 female and 9 male patients were analyzed. The mean age (± SD) was 17.9 ± 6.4 (range 10-34) years. Mean best-corrected visual acuity (± SD) in logMAR was 0.9 ± 0.5 (20/160 ± 20/60). The OCT was suggestive of a focal mass-like lesion primarily involving the inner retinal layers limited externally by the outer plexiform layer (OPL) in 15 eyes (93.7%). The OPL appeared to have a saw-tooth appearance ("intraretinal peaks") in 12 eyes (75%). The convolutions of the OPL were broader and deeper in some eyes (5 eyes, 31.2%), giving an "omega sign" (ω) appearance. The ellipsoid zone appeared intact in 13 eyes (81.2%). The RPE band appeared intact in all eyes.

CONCLUSIONS

Considering the OCT features, available evidence, and embryology, we propose that the true nature of CHRRPE should be reanalyzed. In our series, CHRRPE was noted to be primarily a hamartoma arising from the inner retinal layers. A majority of cases were limited posteriorly by the OPL without any involvement of the outer retinal layers and RPE.

Full-thickness macular hole associated with congenital simple hamartoma of retinal pigment epithelium (CSHRPE)

PURPOSE

To report a unique case of congenital simple hamartoma of retinal pigment epithelium (CSHRPE) associated with full-thickness macular hole (FTMH).

METHODS

A 14-year-old female with a previous diagnosis of simple hamartoma of retinal pigment epithelium in the left eye presented with a 3-week onset of reduced visual acuity in the same eye. Complete ophthalmological examination with spectral domain ocular coherence tomography (SD-OCT) and autofluorescence imaging was carried out. Results were compared with the last 4-year follow-up data.

RESULTS

On examination, visual acuity in the left eye was counting fingers compared to 20/100 documented in the last follow-up. Fundoscopy revealed a nodular, heavily pigmented, circumscribed foveal mass, with 0.5 mm basal diameter and 1.1 mm thickness corresponding to the simple RPE hamartoma. Although the latter remained unchanged throughout the follow-up period, a new lesion at the inferior edge of the hamartoma was noted. SD-OCT confirmed the presence of a FTMH with no evidence of associated epiretinal membrane, vitreomacular traction or posterior vitreous detachment. After explaining the risks and benefits of vitrectomy for FTMH, the patient declined surgery.

CONCLUSIONS

CSHRPE may have associated features such as feeding vessels, retinal surface wrinkling, pigmented vitreous cells, retinal exudation and vitreoretinal adhesion. The case presented herein broadens the clinical spectrum of CSHRPE and emphasizes that despite the benign nature of the lesion, which remains stable without growth, visual loss may occur, attributable to foveal traction and development of FTMH. We postulate that protrusion of the tumor into the vitreous cavity results in tissue stretching and development of anteroposterior and tangential forces which may lead to development of macular hole.

SOLITARY CIRCUMSCRIBED "PEARL WHITE" RETINAL MASS (SO-CALLED RETINAL ASTROCYTIC PROLIFERATION) RESIDES IN DEEP RETINA OR BENEATH RETINA: FINDINGS ON MULTIMODAL IMAGING IN 4 CASES

PURPOSE

To report novel observations of previously described solitary circumscribed retinal astrocytic proliferation using spectral domain optical coherence tomography that suggests this tumor does not arise in the nerve fiber layer as initially believed, but arises within deep retinal or retinal pigment epithelial structures.

METHODS

Retrospective review of four cases.

RESULTS

Patient age ranged from 46 to 75 years. The tumor was pearl white or yellow-white (n = 4, 100%), located in the macula (n = 1, 25%) or macula to equator (n = 3, 75%) regions, and with mean tumor base of 1.2 mm and thickness of 0.8 mm. There were no feeding vessels, intrinsic vessels, subretinal fluid, or vitreoretinal traction. Mild surrounding retinal pigment epithelial hyperplasia and atrophy rimmed each tumor (n = 4, 100%). Fluorescein angiography depicted the mass with early hypofluorescence (n = 3/3, 100%) and late hypofluorescence (n = 2/3, 67%). Spectral domain optical coherence tomography demonstrated the mass with an abruptly elevated "snowball" configuration (n = 4, 100%), with smooth or slightly irregular surface (n = 4, 100%), and originating from deep retina or retinal pigment epithelial (n = 4, 100%), with overlying compression and draping of retinal tissue (n = 4, 100%).

CONCLUSION

This previously described small yellow-white retinal tumor appears to arise in the outer retinal layers and not from the inner retinal layers as formerly believed. This tumor may not be astrocytic as initially believed since it arises deep within the retina, but it could represent a deep glial or pigment epithelial fibrous mass. The pathogenesis and pathology of this rare lesion remain unknown.

Optical Coherence Tomography-Guided Decisions in Retinoblastoma Management

PURPOSE

Assess the role of handheld optical coherence tomography (OCT) in guiding management decisions during diagnosis, treatment, and follow-up of eyes affected by retinoblastoma.

DESIGN

Retrospective, noncomparative, single-institution case series.

PARTICIPANTS

All children newly diagnosed with retinoblastoma from January 2011 to December 2015 who had an OCT session during their active treatment at The Hospital for Sick Children (SickKids) in Toronto, Canada. The OCT sessions for fellow eyes of unilateral retinoblastoma without any suspicious lesion and those performed more than 6 months after the last treatment were excluded.

METHODS

Data collected included age at presentation, sex, family history, RB1 mutation status, 8th edition TNMH cancer staging and International Intraocular Retinoblastoma Classification (IIRC), and number of OCT sessions per eye. Details of each session were scored for indication-related details (informative or not) and assessed for guidance (directive or not), diagnosis (staging changed, new tumors found or excluded), treatment (modified, stopped, or modality shifted), or follow-up modified.

MAIN OUTCOME MEASURES

Frequency of OCT-guided management decisions, stratified by indication and type of guidance (confirmatory vs. influential).

RESULTS

Sixty-three eyes of 44 children had 339 OCT sessions over the course of clinical management (median number of OCT scans per eye, 5; range, 1-15). The age at presentation and presence of a heritable RB1 mutation significantly correlated with an increased number of OCT sessions. Indications included evaluation of post-treatment scar (55%) or fovea (16%), and posterior pole scanning for new tumors (11%). Of all sessions, 92% (312/339) were informative; 19 of 27 noninformative sessions had large, elevated lesions; of these, 14 of 19 were T2a or T2b (IIRC group C or D) eyes. In 94% (293/312) of the informative sessions, OCT directed treatment decisions (58%), diagnosis (16%), and follow-up (26%). Optical coherence tomography influenced and changed management from pre-OCT clinical plans in 15% of all OCT sessions and 17% of directive sessions.

CONCLUSIONS

Optical coherence tomography improves the accuracy of clinical evaluation in retinoblastoma management.

The American Society of Retina Specialists 2016 Founders Award Lecture

Purpose:

To review the current state of the art of retinal tumors with respect to clinical features, imaging, and management.

Methods:

Review of published literature and personal experience from an ocular oncology service.

Results:

There are several tumors that arise from the sensory retina including those of glial origin (astrocytic hamartoma, acquired astrocytoma, and solitary circumscribed retinal astrocytic proliferation), neural origin (retinoblastoma), and vascular origin (hemangioblastoma, cavernous hemangioma, racemose hemangioma, and vasoproliferative tumor). Most retinal tumors are benign with the exception of retinoblastoma and retinal metastasis. Some retinal tumors are associated with systemic oculoneurocutaneous syndromes such as tuberous sclerosis complex (TSC), 13q deletion syndrome, Von Hippel–Lindau disease, and systemic cavernous and racemose hemangioma syndromes with ocular, cutaneous, neurologic, and other findings. Regarding management, recent data indicate that retinal astrocytic hamartoma and retinal achromic patch are key to the diagnosis of TSC and imply greater risk for brain and kidney tumors. Some children with TSC respond to mammalian target of rapamycin inhibitors, controlling brain, kidney, and eye tumors. Children with retinoblastoma are all screened genetically, and systemic evaluation is provided for detection of metastasis and secondary-related tumors. Newer chemotherapy regimens by intravenous or intra-arterial routes have revolutionized retinoblastoma control. Retinal vascular tumors are uncommon but can have serious systemic implications. Therefore, imaging of the brain for related cerebellar hemangioblastoma, midbrain racemose hemangioma, or multifocal cavernomas is performed. Genetic testing for each disease can be revealing.

Conclusions:

Retinal tumors are often benign, can be recognized by clinical and imaging features, and can be associated with important systemic syndromes.

Optical coherence tomography angiography of stimulus evoked hemodynamic responses in individual retinal layers

Blood flow changes are highly related to neural activities in the retina. It has been reported that neural activity increases when flickering light stimulation of the retina is used. It is known that blood flow changes with flickering light stimulation can be altered in patients with vascular disease and that measurement of flicker-induced vasodilatation is an easily applied tool for monitoring functional microvascular alterations. However, details of distortions in retinal neurovascular coupling associated with major eye diseases are not well understood due to the limitation of existing techniques. In this study, flickering light stimulation was applied to mouse retinas to investigate stimulus evoked hemodynamic responses in individual retinal layers. A spectral domain optical coherence tomography (OCT) angiography imaging system was developed to provide dynamic mapping of hemodynamic responses in the ganglion cell layer, inner plexiform layer, outer plexiform layer and choroid layer before, during and after flickering light stimulation. Experimental results showed hemodynamic responses with different magnitudes and time courses in individual retinal layers. We anticipate that the dynamic OCT angiography of stimulus evoked hemodynamic responses can greatly foster the study of neurovascular coupling mechanisms in the retina, promising new biomarkers for retinal disease detection and diagnosis.

Ocular manifestations of Sturge-Weber syndrome: pathogenesis, diagnosis, and management

Sturge–Weber syndrome has been included in the group of phakomatoses that is characterized by hamartomas involving the brain, skin, and eyes. The characteristic facial port-wine stain, involving the first branch of the trigeminal nerve and the embryonic vasculature distribution in this area, leads to several ocular complications of the anterior segment and can involve the eyelids and conjunctiva. The posterior segment of the eyes is also affected with diffuse choroidal hemangiomas. However, the most frequent ocular comorbidity is glaucoma with a prevalence rate ranging from 30%–70%. Glaucoma is related to anterior chamber malformations, high episcleral venous pressure (EVP), and changes in ocular hemodynamics. Glaucoma can be diagnosed at birth, but the disease can also develop during childhood and in adults. The management of glaucoma in Sturge–Weber syndrome patients is particularly challenging because of early onset, frequently associated severe visual field impairment at the time of diagnosis, and unresponsiveness to standard treatment. Several surgical approaches have been proposed, but long-term prognosis for both intraocular pressure control and visual function remains unsatisfactory in these patients. Choroidal hemangiomas may also lead to visual impairment thorough exudative retinal detachment and macular edema. Treatment of exudative hemangioma complications is aimed at destructing the tumor or decreasing tumor leakage.

Long-term visual outcomes in intraocular retinoblastoma with eye preservation

PURPOSE

Inconsistent data exist on long-term visual outcomes in survivors of retinoblastoma. No studies have been reported on role of ocular coherence tomography (OCT) in predicting visual acuity. We assessed visual acuity in patients with retinoblastoma treated at our center in whom affected eyes were preserved.

METHODS

Patients who had completed a 2-year follow-up and were more than 5 years of age at assessment were included. Clinical data were obtained from database and factors predicting visual acuity were analyzed. OCT was performed in these patients to assess central macular thickness (CMT).

RESULTS

Visual outcomes were assessed in 45 eyes of 43 patients, of which 38 (88 %) had bilateral retinoblastoma. The median age at diagnosis was 12 months. Sixty percent (27/45) had International classification of retinoblastoma group C or D disease with 40 % eyes showing macular lesions. The far visual acuity was better than 6/12 in 53 % (24/45), 6/12 to 6/60 in 40 % (18/45) and 6/60 in 7 % (6/60). Macular location and International classification of retinoblastoma predicted poor vision (p = 0.06 and 0.07, respectively). CMT was less than 200 μm in 3 of 36 eyes (8 %) and 1 eye showed epiretinal membrane. Radiotherapy was associated with foveal thinning (p = 0.003). Two of 3 eyes with foveal thinning had a vision of 6/60.

CONCLUSIONS

Good visual outcomes were observed in half of retinoblastoma patients treated with eye preservation. Macular location and International classification of retinoblastoma group C and D predicted poor visual acuity, while previous radiotherapy predicted foveal thinning, which was associated with poor visual acuity.

Detection and Intraretinal Localization of an 'Invisible' Retinoblastoma Using Optical Coherence Tomography

PURPOSE

To report the use of handheld spectral-domain optical coherence tomography (HHSD OCT) to identify and define the intraretinal location of a small retinoblastoma that was not detectable by indirect ophthalmoscopy.

METHODS

This is a retrospective case report of a tumor identified with HHSD OCT in a single patient.

RESULTS

A 7-week-old male was diagnosed with unilateral group E retinoblastoma in the right eye. An enucleation was completed successfully with histopathologic confirmation of the diagnosis. The normal left eye was monitored for the development of retinoblastoma, and 10 weeks after diagnosis, three new small retinoblastomas were noted in the posterior pole. Identification of the smallest of the three tumors was facilitated by HHSD OCT; it was adjacent to the optic nerve head, and involved the outer nuclear layer, outer plexiform layer, and inner nuclear layer, with the inner retina draping over the tumor.

CONCLUSION

HHSD OCT can aid the ocular oncologist in the identification of very small retinoblastomas before they are visible to the eye, which allows for earlier and potentially vision-sparing treatment of these lesions. Additionally, the ability to identify these very small tumors and to localize them anatomically within the retinal layers may aid in our understanding of retinoblastoma tumorigenesis.