Circumscribed choroidal hemangioma: An overview of clinical manifestation, diagnosis and management

Ultrasound Biomarkers: Contrast-enhanced Ultrasound and Nakagami Imaging to Differentiate Benign and Malignant Choroidal Tumor

PURPOSE

We hypothesized that contrast-enhanced ultrasound (CEUS) using a microbubble technique to quantify microvascular changes and Nakagami imaging for tissue characterization would provide a new approach for diagnosing and differentiating benign and malignant choroidal lesions.

METHODS

Five patients with choroidal melanoma (CM) and five patients with choroidal hemangioma (CH) were selected. Definity®, which contains perflutren microbubbles, was administered as a slow IV bolus (1 ml). CEUS was performed for 1 min postinjection of the contrast agent with ultrasound radiofrequency data acquired from 10 s to 60 s. The contrast value was calculated for the whole tumor region. A gradient magnitude method was used for each postcontrast frames with 1-second interval, and the time-averaged value in pixel intensity gradient of postinjection frames was estimated and reported. Based on the Nakagami statistical distribution model, two Nakagami parameters, m and Ω, where m (shape parameter), representing tissue heterogeneity, and Ω (scale parameter), representing the average energy of backscattered signals, were studied.

RESULTS

CEUS analysis showed that the time-averaged estimated contrast was significantly higher (p = 0.008) for CH compared to CM. Furthermore, the time-averaged contrast within the normal choroidal region was significantly higher than the choroidal tumor region for both CH and CM (p = 0.001 for CH cases and p < 0.0001 for CM cases). Nakagami analysis showed that the m estimates were significantly higher (p = 0.032) for CH (m = 0.61) than for CM (m = 0.28), indicating that CH is a more heterogeneous tumor than CM. The Ω estimates were significantly higher (p = 0.0019) for CH (Ω = 0.15) compared to CM (Ω = 0.03). These results may be due to the more vascular structures in CH compared to CM.

CONCLUSIONS

Quantitative intensity-based perfusion analysis using CEUS and backscattering tissue analysis using Nakagami imaging can provide valuable insights to differentiate benign and malignant choroidal lesions.

Comparison of the therapeutic effects of photodynamic therapy, transpupillary thermotherapy, and their combination on circumscribed choroidal haemangioma

OBJECTIVE

To characterize the clinical and imaging features of circumscribed choroidal hemangioma (CCH), and to evaluate individualized treatment efficiency of photodynamic therapy (PDT), transpupillary thermotherapy (TTT), or their combination, followed by retrobulbar injection of betamethasone on CCH resolvement.

METHODS

Forty-nine patients with CCHs who underwent PDT, TTT or PDT+TTT treatments were retrospectively collected. Their treatment efficacy were compared by analyzing the change of best corrected visual acuity (BCVA), subretinal fluid (SRF) and CCH lesion characteristics.

RESULTS

PDT, TTT and PDT+TTT were respectively administrated in 17, 11 and 21 patients. No significant difference in age, gender, affected eyes and tumor location across the three groups. Baseline BCVA were 0.41 ± 0.28, 0.62 ± 0.30 and 0.24 ± 0.24 for PDT, TTT and PDT+TTT groups, respectively (F=6.572, P=0.003). CCH treated by three strategies showed significant difference in maximum tumor basal diameter, SRF areas and macula involvement prior to the treatment (P<0.05). Patients receiving PDT+TTT exhibited larger tumor basal diameter, more SRF, higher ratio of macular involvement than other groups. A total of 38 (77.6%) cases had good visual acidity with final BCVA ≥0.5 after treatments. PDT and PDT+TTT treatment groups acquired more vision improvement (0.27±0.23 and 0.31±0.26) in BCVA than TTT group (0.09±0.13). All SRF were resolved within two weeks of treatment and no recurrent SRF were found.

CONCLUSION

Three treatments showed good performance in improving visual function and controlling SRF, and individualized treatment should be selected primarily by the tumor location,and then the tumor size and presence of SRF.

Ruthenium-106 (106Ru) plaque brachytherapy for treatment of circumscribed choroidal hemangioma

PURPOSE

To describe the clinical and imaging features of circumscribed choroidal hemangiomas (CCH) and their treatment outcomes with Ruthenium-106 (106Ru) plaque brachytherapy.

METHODS

Retrospective study of 24 patients (24 eyes) diagnosed with CCH and treated with 106Ru plaque between 2017 and 2022. Analysis included pre- and post-treatment clinical and imaging features such as tumor regression, reduction in height, subretinal fluid (SRF) resolution, and change in best-corrected visual acuity (BCVA).

RESULTS

The mean age at presentation was 36 years (range, 16-57). The most common tumor location was the temporal quadrant (n = 19) with macular involvement (n = 13). Associated features were macular SRF (n = 22) and inferior exudative retinal detachment (n = 10). Nineteen of the 24 patients underwent primary treatment, whereas 5 patients underwent plaque as a salvage treatment. The mean tumor apex dose was 40 Gy. At a median follow-up of 7.5 months (range 3-65 months), 18 eyes showed complete regression, whereas 6 eyes showed partial regression. The mean height decreased from 4.8 (SD 1.28) mm at presentation to 2.5 (SD 1.63) mm. Median BCVA improved from logMAR 1.2 (IQR 0.4-2) at baseline to logMAR 1.05 (IQR 0.1-1.95) (p = 0.4). Complete resolution of the macula and tumor SRF was observed in 15 (68%) and 13 (57%) eyes, respectively. The radiation-related complications observed were radiation maculopathy (4 eyes), retinopathy (1 eye), and vitreous hemorrhage (1 eye).

CONCLUSION

Ruthenium-106 plaque brachytherapy is effective for CCH (> 3 mm height) as a primary and salvage treatment for tumors unresponsive to other modalities.

New insights on circumscribed choroidal hemangioma: "bench to bedside"

Circumscribed choroidal hemangioma is a rare vascular hamartoma of the choroid, presenting as a red-orange mass at the posterior pole on fundoscopic examination. Despite its benign origin, associated complications such as subretinal fluid, serous retinal detachment, retinoschisis and neovascular glaucoma may lead to serious visual impairment in more than half patients. Because of its similarity to amelanotic choroidal melanoma and choroidal metastasis, differential diagnosis is still challenging for specialists. Multimodal imaging such as ultrasonography, fluorescein angiography, indocyanine green angiography, optical coherence tomography, and optical coherence tomography angiography guides the clinician to the correct diagnosis and the proper follow-up. Treatment is indicated in symptomatic cases in order to resolve exudation and improve visual acuity. Treatment options include photocoagulation, transpupillary thermotherapy, radiation therapy, photodynamic therapy and anti-vascular endothelial growth factor therapy. Currently, photodynamic therapy is the treatment of choice due to its effectiveness and safety. The purpose of this review is to describe the latest knowledge in the etiopathogenesis of the circumscribed choroidal hemangioma, the most recent multimodal imaging findings, and the available treatment options.

[Circumscribed choroidal hemangioma and non-pigmented choroidal melanoma: clinical, instrumental and molecular genetic features]

Circumscribed choroidal hemangioma (CCH) and early non-pigmented choroidal melanoma (CM) have similar clinical, ultrasound and morphometric features, which in some cases makes their differential diagnosis difficult. There are few studies in the literature devoted to a comparative analysis of the molecular genetic features of CCH and non-pigmented CM, and the results of those studies are contradictory.

PURPOSE

This study attempts to develop a method of non-invasive molecular genetic differential diagnostics of CCH and non-pigmented CM.

MATERIAL AND METHODS

Based on the results of clinical and instrumental examination methods, 60 patients (60 eyes) with CCH (n=30) and non-pigmented CM (n=30) were included in this prospective study. The control group consisted of 30 individuals without intraocular tumors. Mutations in the GNAQ/GNA11 genes were determined by real-time PCR using the analysis of genomic circulating tumor DNA isolated from peripheral blood plasma. The average follow-up period was 12.1±1.8 months.

RESULTS

The study revealed a significant association of mutations in exons 4 and 5 of the GNAQ/GNA11 genes with the presence of non-pigmented CM (27/30; 90%). These mutations were not detected in the group of patients with CCH. Mutations in exons 4 and 5 of the GNAQ/GNA11 genes were also not detected in the control group of healthy individuals.

CONCLUSION

This study proposes a method of non-invasive and low-cost differential diagnostics based on molecular genetic analysis and detection of mutations in exons 4 and 5 of the GNAQ and GNA11 genes, which are specific for CM (90%).

A Case of Circumscribed Choroidal Hemangioma Treated With Proton Beam Therapy and Followed Up for 15 Years

Circumscribed choroidal hemangiomas are rare and benign tumors but often have a progressive course and are complicated by retinal detachment and glaucoma. The effectiveness of external radiation for large tumors that are difficult to treat with photodynamic therapy was recently reported; however, few studies have conducted long-term follow-ups. We encountered a case of localized choroidal hemangioma that was treated with proton beam therapy and followed up for 15 years. A 37-year-old man was diagnosed with a 10 × 4 mm circumscribed choroidal hemangioma involving the macular area with retinal detachment. Proton beam therapy was performed at 26.4 Gy relative biological effectiveness (RBE) in 8 fractions. The choroidal hemangioma gradually shrank over three years, and the retinal detachment also improved. A cataract developed on the affected side 11 years after irradiation, and eye coordination issues developed 15 years after irradiation. Glaucoma was not observed during the follow-up period; however, visual acuity did not recover, and the patient developed light perception. Although vision was not preserved, proton beam therapy effectively shrank the tumor and maintained quality of life.

Subretinal autofluorescent deposits: A review and proposal for clinical classification

Subretinal autofluorescent deposits (SADs) may be found in the posterior pole, associated with very various conditions. These disorders usually present a typical pattern of autofluorescent lesions seen on short-wavelength fundus autofluorescence. We describe SADs according to their putative pathophysiological origin and also according to their clinical pattern, i.e., number, shape, and usual location. Five main putative pathophysiological origins of SADs were identified in disorders associated with an intrinsic impairment of phagocytosis and protein transportation, with excess of retinal pigment epithelium phagocytic capacity, with direct or indirect retinal pigment epithelium injury, and/or disorders associated with long-standing serous retinal detachment with mechanical separation between the retinal pigment epithelium and the photoreceptor outer segments. Clinically, however, they could be classified into eight subclasses of SADs, as observed on fundus autofluorescence as follows: single vitelliform macular lesion, multiple roundish or vitelliform lesions, multiple peripapillary lesions, flecked lesions, leopard-spot lesions, macular patterned lesions, patterned lesions located in the same area as the causal disorder, or nonpatterned lesions. Thus, if multimodal imaging may be required to diagnose the cause of SADs, the proposed classification based on noninvasive, widely available short-wavelength fundus autofluorescence could guide clinicians in making their diagnosis decision tree before considering the use of more invasive tools.

Diffuse choroidal hemangioma in pregnancy: Symptomatic diffuse choroidal hemangioma spontaneously resolving postpartum

We present the case of a pregnant young woman with symptomatic diffuse choroidal hemangioma (CH), diagnosed with Sturge-Weber syndrome (SWS). Three months postpartum, there was full spontaneous resolution of the subretinal fluid and improvement in the visual acuity (VA). A 29-year-old, 31-week pregnant female with a coagulation disorder and enoxaparin (clexane) treatment, complained of a left visual disturbance of 2 weeks duration. On examination, the right eye was normal; left eye VA was 6/12 (20/40) with a left eyelid port-wine stain and on funduscopic examination there was a serous retinal detachment. On ultrasound, there was diffuse thickening of the choroid with a focus superior and nasal to the disc with active vascularization - a diagnosis of diffuse CH was made. Magnetic resonance imaging (MRI) and MR venography studies of the brain and orbit revealed engorged orbital vasculature, and the diagnosis of SWS was made. Three months after Cesarean section with birth of a healthy baby boy, VA returned to 6/9 with full resorption of subretinal fluid. On fundoscopic exam, there were no retinal or vein occlutions but there were tortuous blood vessels with A-V crossing. This is a rare case of newly diagnosed SWS with symptomatic diffuse CH in pregnancy. Postpartum, there was full resolution of the subretinal fluid. A watchful waiting approach can be considered in such cases.

Effects and Assessment of the Optic Pathway After Management with Stereotactic Radiosurgery for Intracranial Tumors: A Comprehensive Literature Review

Intracranial tumors are treated through a minimally invasive procedure called stereotactic radiosurgery (SRS), which uses precisely targeted radiation beams. When SRS is used to treat tumors in or near the optic pathway, which is responsible for transmitting visual information from the eyes to the brain, it is essential to assess the effects of treatment on visual function. The optic pathway is considered relatively radiation-sensitive, and high doses of radiation can lead to visual impairment or loss. Various methods can be used to assess the effects of SRS on the optic pathway, including visual acuity testing, visual field testing, and imaging studies. These assessments can be performed before and after treatment to track changes in visual function and detect potential complications or side effects. Assessing the optic pathway after management with SRS for intracranial tumors is essential to the treatment process to ensure that patients receive the best possible outcomes while minimizing the risk of complications. Close collaboration between the multidisciplinary team is often necessary to optimize treatment planning and monitoring of treatment response. In this review, we conducted an extensive analysis of the effects of radiation in patients with intracranial tumors after receiving radiotherapy.

Occurrence of circumscribed choroidal hemangioma accompanied by polypoidal choroidal vasculopathy and branch retinal vein occlusion: a case report

BACKGROUND

Circumscribed Choroidal hemangioma (CCH) is a kind of hamartoma that is caused by congenital vascular malformation. And, polypoidal choroidal vasculopathy (PCV) is an exudative maculopathy. There is no literature indicating that there is a correlation between the occurrences of CCH and PCV.

CASE PRESENTATION

A 66-year-old male presented with decreased vision of his left eye for 4 years. Fundus photograph showed that the branches of blood vessels at the supratemporal retina were occluded in white lines, an orange lesion could be seen in the subnasal retina and mottled, yellowish white lesions were accompanied by punctate hard exudation in the macular in the left eye. The Fundus autofluorescence (FAF), fundus fluorescein angiography (FFA), indocyanine green angiography (ICGA) and Spectral domain optical coherence tomography (OCT) were done. There was a diagnosis of CCH, PCV and branch retinal vein occlusion accompanied with retinoschisis of the left eye.

CONCLUSION

This article reports on a case of an elderly male Chinese patient with CCH and PCV accompanied by branch retinal vein occlusion with retinoschisis in the left eye. The common lesions are choroidal vascular abnormalities. Whether hypertension is related to CCH, PCV and branch retinal vein occlusion remains to be further studied.

LONG TERM RESULTS OF PHOTODYNAMİC THERAPY IN INTRAOCULAR TUMORS

PURPOSE

To report long term results of photodynamic therapy (PDT) as treatment for intraocular tumors METHODS: Retrospective interventional case series of 15 patients. All patients treated with standard-fluence PDT (83 seconds; 50 J/cm2) using verteporfin.

OUTCOME MEASURES

Tumor diameter, tumor thickness, subretinal fluid resolution, best-corrected visual acuity,intraocular pressure and PDT complications.

RESULTS

10 patients (66.7% of total patients) were diagnosed with choroidal hemangioma, 3 patients (20% of total patients) were diagnosed with choroidal melanoma, and 2 patients (13,3% of total patients) were diagnosed with choroidal osteoma.. Mean follow-up time was 33±18 months. The mean visual acuity was determined as 1.29±0.98 logMAR in the examinations just before the PDT application. At the end of the follow-up period, the mean visual acuity was calculated as 1.41±1.07 logMAR. While VA increased in 3 (20%) patients and decreased in 5 (33.3%) patients; It was determined that VA value did not change after treatment in 7 (46.7%) patients. The mean lesion diameter before PDT was 6573 ±2115 µm (range; 1500-10000µm). The mean tumor thickness before PDT was 3624 ±1404 µm (range; 600-6000µm). The mean lesion diameter after treatment was 6026±2521 µm (range; 0-9000µm), and the mean tumor thickness after treatment was 2280 ±1740 µm (range; 0-6000 µm).After the PDT, tumor size decreased in 8 (53.3%) patients, increased in 3 (20%) patients, and no change in tumor size was observed in 4 (26.7%) patients. Mean IOP values ​​of all patients were 14.06±3.17 mmHg before treatment; after treatment, it was measured as 13.46±1.70 mmHg. After the treatment, geographic atrophy developed in 1 (6.7%) patient, cystoid macular edema developed in 1 (6.7%) patient, Retinal Pigment Epithelium (RPE) and choroidal atrophy developed in 1 (6.7%) patient.

CONCLUSION

There are not enough cases of each to clearly distinguish between these 3 types of ocular cancers however PDT may be a good option in the treatment of intraocular tumors with the chance of selective treatment and successful responses in selected cases.

β-Adrenoreceptors as Therapeutic Targets for Ocular Tumors and Other Eye Diseases-Historical Aspects and Nowadays Understanding

β-adrenoreceptors (ARs) are members of the superfamily of G-protein-coupled receptors (GPCRs), and are activated by catecholamines, such as epinephrine and norepinephrine. Three subtypes of β-ARs (β₁, β₂, and β₃) have been identified with different distributions among ocular tissues. Importantly, β-ARs are an established target in the treatment of glaucoma. Moreover, β-adrenergic signaling has been associated with the development and progression of various tumor types. Hence, β-ARs are a potential therapeutic target for ocular neoplasms, such as ocular hemangioma and uveal melanoma. This review aims to discuss the expression and function of individual β-AR subtypes in ocular structures, as well as their role in the treatment of ocular diseases, including ocular tumors.

Cytokine Concentrations in Aqueous Humor of Eyes With Circumscribed Choroidal Hemangioma

PURPOSE

Anti-vascular endothelial growth factor (anti-VEGF) treatment are now widely used in patients with circumscribed choroidal hemangioma (CCH), however the concentrations of VEGF and other cytokines in CCH patients have not been known before. The study was conducted to compare various cytokine concentrations in the aqueous humor of eyes with CCH and control.

METHODS

A total of 16 eyes of 16 patients with CCH, and 15 eyes of 15 patients with cataract as the control group were examined. Aqueous humor samples were assessed for 30 angiogenic and inflammatory cytokines by Luminex bead-based multiplex array.

RESULTS

Significantly, compared with control group, higher concentrations of VEGF-A and IP-10 were found in the CCH patients (P = 0.002 and P < 0.001).

CONCLUSIONS

VEGF-A and IP-10 might be involved with the angiogenic and antiangiogenic process in CCH patients, which provides new insight into the pathophysiology of CCH and could be potential targets for treatment.

Circumscribed choroidal hemangioma: Comparative efficacy of transpupillary thermotherapy, indocyanine green-enhanced transpupillary thermotherapy, and photodynamic therapy and analysis of baseline clinical features effecting treatment outcomes

PURPOSE

To compare the efficacy of transpupillary thermotherapy (TTT), indocyanine green-enhanced TTT (ICG-TTT), and photodynamic therapy (PDT) in the management of circumscribed choroidal hemangioma (CCH) and to investigate the baseline clinical features effecting treatment outcomes METHODS: Retrospective review of clinical records of 60 eyes with CCH which underwent TTT (25), ICG-TTT (22), or PDT (13). Main study outcomes were 1) final visual acuity (VA) ≤20/200, 2) <2 Snellen lines VA increase, 3) persistent subretinal fluid (SRF), and 4) <20% decrease in tumor thickness.

RESULTS

Multivariable factors associated with final VA ≤20/200 included longer duration of symptoms (p = 0.015), lower initial VA (p = 0.030), and presence of retinoschisis overlying the tumor (p = 0.047). Multivariable factors for <2 Snellen lines VA increase were longer duration of symptoms (p = 0.018) and previous failed treatment (p = 0.003). By multivariable analysis, the only significant factor for persistent SRF was the presence of retinoschisis (p = 0.001). Multivariable factors associated with a decrease in tumor thickness by <20% were smaller initial tumor thickness (p = 0.045) and presence of retinoschisis (p = 0.014). By Pearson Chi-Square/Fisher Exact Test, final VA ≤20/200 rates (48.0%, 13.6%, 30.8% respectively, p = 0.041) and VA improvement by <2 lines rates (64.0%, 27.3%, 38.5% respectively, p = 0.036) were significantly different between TTT, ICG-TTT, and PDT groups. However, by post hoc analysis, ICG-TTT yielded statistically better outcomes compared to TTT with respect to final visual acuity (VA) ≤20/200 (p = 0.012) and <2 Snellen lines VA increase (p = 0.012).

CONCLUSIONS

Longer symptom duration, previous failed treatment, lower initial VA, and presence of retinoschisis were risk factors for worse visual outcomes. Eyes with retinoschisis displayed more SRF persistence after treatment. Smaller initial tumor thickness and presence of retinoschisis were risk factors for <20% decrease in tumor thickness.

A Pulmonary Pleomorphic Carcinoma Patient with Exudative Retinal Detachment Secondary to Choroid Metastasis as Initial Presentation-A Case Report

Choroid metastasis is the initial presentation of pleomorphic carcinoma (PC) of the lung. PC is classified as poorly differentiated non-small cell lung carcinoma. It has a tendency to metastasize early and has a poor response to chemotherapy, which often results in poor prognosis. We report the case of a 63-year-old woman with a one-month history of deteriorating vision in the left eye. Fundus examination, fluorescein angiography, indocyanine green angiography, and B-scan sonography demonstrated choroidal metastasis of the left eye. Positron emission tomography/computed tomography (PET/CT) revealed a tumor with increased uptake in the left upper lung. Subsequent bronchoscopic biopsy confirmed a pleomorphic carcinoma of the lungs. Choroid metastasis as an initial presentation of PC in the lung is rare. Usually, it represents the late course of disseminated disease with hematogenous spread. Prompt diagnosis is imperative for patients to immediately initiate treatment.

The Impacts of Episcleral Plaque Brachytherapy on Ocular Motility

Background: To investigate the effect of various factors on ocular motility disturbance after episcleral plaque brachytherapy with Ruthenium 106 (¹⁰⁶Ru).Methods: Twenty consecutive patients who underwent plaque brachytherapy for all types of intraocular tumors were included in this interventional prospective case series. Ruthenium-106 was used with a mean total dose of 93.2 ± 21.2 Gy toward the tumor apex. Full orthoptic examinations were performed before and after the surgery.Results: The average follow-up time was 6 months (range: 4-9 months). Two (10%) out of 20 patients developed exotropia. The mean age of patients without strabismus was higher than the patients with strabismus (49.8 ± 10.7 years compared to 23 ± 4.2 years, respectively) (p = .011). Strabismus was observed in the patients who had tumors with larger apical diameters (7.6 ± 2 mm compared to 4.1 ± 0.9 mm, respectively) (p = .021). The mean radiation dose to the tumor base in the group with strabismus was higher than the group without motility disturbance (1046.5 ± 604.1 Gy compared to 384.3 ± 175.3, respectively) (p = .021). Most tumors were located in the inferotemporal fundus (30%), followed by supratemporal location (25%), supranasal (10%), and macular region (10%). A higher percentage of patients with postoperative strabismus underwent muscle manipulation compared to the patients who did not develop this complication (100% compared to 38.9%).Conclusion: Manipulation of the extraocular muscles, high doses of radiation, and low vision could cause strabismus after episcleral plaque brachytherapy.

High resolution mass spectrometry provides novel insights into the ganglioside pattern of brain cavernous hemangioma

In this study we have optimized nanoelectrospray ionization (nanoESI) high resolution mass spectrometry (HR MS) performed on Orbitrap instrument in the negative ion mode for the determination of the composition and structure of gangliosides extracted from human brain cavernous hemangioma. The optimized HR MS platform, allowed the discrimination of 62 ions, corresponding to 52 different ganglioside species, which represents roughly twice the number of species existing in the current inventory of human brain hemangioma-associated gangliosides. The experiments revealed a ganglioside pattern dominated by GD-type of structures as well as an elevated incidence of species characterized by a low degree of sialylation and short glycan chains, including asialo GA1 (d18:1/18:0), which offer a new perspective upon the ganglioside composition in this benign tumor. Many of the structures are characteristic for this type of tumor only and are to be considered in further investigations for their potential use in early brain hemangioma diagnosis based on molecular markers. The detailed fragmentation analysis performed by collision-induced dissociation (CID) tandem MS provided information of structural elements related to the glycan core and ceramide moiety, which confirmed the molecular configuration of GD3 (d18:1/24:1) and GD3 (d18:1/24:2) species with potential biomarker role.