TRANSIENT SUBRETINAL HEMORRHAGE AFTER PHOTODYNAMIC THERAPY OF SUBFOVEAL CHOROIDAL OSTEOMA Melis Palamar, MD,* Onder Uretmen, MD,* Kaan Gu¨ndu¨z, MD†
Purpose: To report a case of choroidal osteoma that developed subretinal hemorrhage after photodynamic therapy (PDT). Methods: Interventional case report. Results: An 8-year-old boy was brought to our attention because of mild visual loss in his left eye. The visual acuity was 20/25. A subfoveal yellow-orange–colored lesion, measuring 5.0 mm 3 4.5 mm in base diameter was detected in the left eye. B-mode ultrasonography showed an acoustically solid 2.0-mm-thick mass with orbital shadowing. Orbital computed tomography confirmed the presence of calcium, and choroidal osteoma was diagnosed. As there was a decrease in the best-corrected visual acuity (20/30) and the lesion showed growth (6.0 mm 3 6.0 mm), PDT was performed at 6 months follow-up. The day after PDT, the visual acuity was counting fingers at 1 m and a subretinal hemorrhage over the lesion was detected. Two weeks after PDT, subfoveal hemorrhage dissappeared with some retinal pigment epithelial hyperplasia and visual acuity increased back to 20/30. Conclusion: Although PDT can induce decalcification in choroidal osteomas, it should not be performed in subfoveal osteomas unless there is evidence to treat the lesion such as the presence of choroidal neovascularization. RETINAL CASES & BRIEF REPORTS 6:166–168, 2012
From the *Department of Ophthalmology, Ege University Faculty of Medicine, Izmir, Turkey; and †Department of Ophthalmology, Ankara University Faculty of Medicine, Ankara, Turkey.
Case Report An 8-year-old boy was brought to our attention because of mild visual loss in his left eye. The best-corrected visual acuity was 20/ 20 in the right eye and 20/25 in the left eye. The right eye was normal. In the left eye, there was a subfoveal yellow-orange– colored lesion, measuring 5.0 mm 3 4.5 mm in base diameter (Figure 1A). B-mode ultrasonography showed an acoustically solid mass measuring 2.0 mm in thickness with orbital shadowing (Figure 1B). Orbital computed tomography confirmed the presence of calcium (Figure 1C). Optical coherence tomography showed normal thickness photoreceptor layer and no subretinal fluid over the lesion (Figure 1D). On fluorescein angiography, the lesion showed patchy hyperfluorescence starting in the late venous phase, leading to confluent hyperfluorescence and leakage in the late phase, but no choroidal neovascularization was detected (Figure 1E). Choroidal osteoma was diagnosed, and observation was advised. At 6-month follow-up, the best-corrected visual acuity in the affected eye decreased to 20/30. Fundus examination showed that the choroidal osteoma increased in size to 6.0 mm 3 6.0 mm in base diameter (Figure 2A). Tumor thickness remained at 2.0 mm. These findings caused parental pressure and a standard fluence PDT, a standard fluence PDT (600 mW/cm2 intensity) was administered after an intravenous infusion of verteporfin (6 mg/m2). The lesion was treated with three spots. The day after PDT, best-corrected visual
C
horoidal osteoma is a rare intraocular tumor characterized by the presence of bone in the choroid. The tumor is usually diagnosed in the second or third decade of life although it can be seen in children as well.1 Growth is seen in 40% and choroidal neovascularization in 33% of cases. Tumor decalcification can occur spontaneously or can be induced by laser photocoagulation or photodynamic therapy (PDT). Decalcification minimizes further growth to the fovea.2–4 We report a case with subfoveal choroidal osteoma that developed subretinal hemorrhage after PDT. The authors have no conflicts of interest to disclose. Reprint requests: Melis Palamar, MD, Ege Universitesi Tip Fakultesi Hastanesi, Goz Hastaliklari AD, 35040 Bornova, Izmir, Turkey; e-mail: [email protected]
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Fig. 1. A, Fundus photograph of the left eye showing subfoveal choroidal osteoma measuring 5.0 mm 3 4.5 mm in base. B, B-mode ultrasonography of the choroidal osteoma showing a 2.0-mmthick tumor with acoustic solidity, high echogenicity consistent with calcium, and posterior orbital shadowing. C, Orbital computed tomography showing the presence of calcification in the left eye. D, Optical coherence tomography of left eye showing absence of subretinal fluid overlying the tumor. E, Latephase fluorescein angiogram of the left eye showing hyperfluorescence and leakage over the lesion.
acuity in the left eye was found to be counting fingers at 1 m. On fundus examination subretinal hemorrhage over the lesion was detected (Figure 2B). Optical coherence tomography revealed high subretinal reflectivity and loss of foveal contour, consistent with the
Fig. 2. A, Fundus photograph 6 months after the initial examination showing that the choroidal osteoma showed increase from its initial base diameter. B, Fundus photograph 1 day after PDT demonstrating subretinal hemorrhage over the lesion. C, The OCT of the left eye 1 day after PDT showing high subretinal reflectivity and loss of the foveal contour. D, Optical coherence tomography of the left eye 2 weeks after PDT demonstrating resolution of the subretinal hemorrhage and the normal foveal contour. E, Fundus photograph 2 weeks after PDT showing complete resolution of the subretinal hemorrhage. OCT, optical coherence tomography.
clinically observed subretinal hemorrhage (Figure 2C). One week after PDT, the subfoveal hemorrhage started to dissolve and bestcorrected visual acuity increased to 20/50. Two weeks after PDT, subfoveal hemorrhage dissappeared with some retinal pigment
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epithelial hyperplasia (Figure 2, D and E). Best-corrected visual acuity increased back to 20/30.
Discussion Vision loss in choroidal osteoma might develop from photoreceptor degeneration, subfoveal fluid, and subfoveal hemorrhage from choroidal neovascularization. Visual acuity is better in cases without foveal involvement.2 There is insufficient information in the literature about PDT in choroidal osteomas. Shields et al4 reported that PDT can be used in extrafoveal choroidal osteoma to induce decalcification and prevent growth to the fovea. They pointed out that these results should not be extrapolated to subfoveal osteomas. On the basis of the experiences gained from this case, we conclude that PDT should not be used in subfoveal osteomas unless there is compelling evidence to treat the lesion such as the presence of choroidal neovascularization. The reasons against doing PDT in subfoveal osteomas are threefold. First, PDT induces decalcification of subfoveal choroidal osteoma, which can result in vision decrease because of retinal pigment epithelial loss. Second, PDT is known to cause inflammation, ischemia, and vascular endothelial growth factor increase in the retina, which
may trigger subretinal hemorrhage via angiogenesis and increased vascular permeability, as in our case.5,6 Third, choroidal ischemia can develop after PDT of choroidal osteomas, similar to cases with age-related macular degeneration or polypoidal choroidal vasculopathy treated with this modality.5,6 Key words: children, choroidal osteoma, photodynamic therapy, subretinal hemorrhage. References 1. Shields JA, Shields CL. Osseous, myogenic, neurogenic, fibrous, and histiocytic tumors of the uvea. In: Shields JA, Shields CL, eds. Intraocular Tumors. A Text and Atlas. Philadelphia, PA: Saunders; 2008:264–289. 2. Shields CL, Sun H, Demirci H, Shields JA. Factors predictive of tumor growth, tumor decalcification, choroidal neovascularization, and visual outcome in 74 eyes with choroidal osteoma. Arch Ophthalmol 2005;123:1658–1666. 3. Trimble SN, Schatz H. Decalcification of a choroidal osteoma. Br J Ophthalmol 1991;75:61–63. 4. Shields CL, Materin MA, Mehta S, et al. Regression of extrafoveal choroidal osteoma following photodynamic therapy. Arch Ophthalmol 2008;126:135–137. 5. Oh IK, Huh K, Oh J. Risk factors for retinal hemorrhage after photodynamic therapy in age-related macular degeneration. Ophthalmologica 2009;223:78–84. 6. Matsushita S, Naito T, Takebayashi M, et al. The prognosis of cases with massive subretinal hemorrhage after photodynamic therapy. J Med Invest 2008;55:231–235.
Purpose: To report a case of choroidal osteoma that developed subretinal hemorrhage after photodynamic therapy (PDT). Methods: Interventional case report. Results: An 8-year-old boy was brought to our attention because of mild visual loss in his left eye. The visual acuity was 20/25. A subfoveal yellow-orange–colored lesion, measuring 5.0 mm 3 4.5 mm in base diameter was detected in the left eye. B-mode ultrasonography showed an acoustically solid 2.0-mm-thick mass with orbital shadowing. Orbital computed tomography confirmed the presence of calcium, and choroidal osteoma was diagnosed. As there was a decrease in the best-corrected visual acuity (20/30) and the lesion showed growth (6.0 mm 3 6.0 mm), PDT was performed at 6 months follow-up. The day after PDT, the visual acuity was counting fingers at 1 m and a subretinal hemorrhage over the lesion was detected. Two weeks after PDT, subfoveal hemorrhage dissappeared with some retinal pigment epithelial hyperplasia and visual acuity increased back to 20/30. Conclusion: Although PDT can induce decalcification in choroidal osteomas, it should not be performed in subfoveal osteomas unless there is evidence to treat the lesion such as the presence of choroidal neovascularization. RETINAL CASES & BRIEF REPORTS 6:166–168, 2012
From the *Department of Ophthalmology, Ege University Faculty of Medicine, Izmir, Turkey; and †Department of Ophthalmology, Ankara University Faculty of Medicine, Ankara, Turkey.
Case Report An 8-year-old boy was brought to our attention because of mild visual loss in his left eye. The best-corrected visual acuity was 20/ 20 in the right eye and 20/25 in the left eye. The right eye was normal. In the left eye, there was a subfoveal yellow-orange– colored lesion, measuring 5.0 mm 3 4.5 mm in base diameter (Figure 1A). B-mode ultrasonography showed an acoustically solid mass measuring 2.0 mm in thickness with orbital shadowing (Figure 1B). Orbital computed tomography confirmed the presence of calcium (Figure 1C). Optical coherence tomography showed normal thickness photoreceptor layer and no subretinal fluid over the lesion (Figure 1D). On fluorescein angiography, the lesion showed patchy hyperfluorescence starting in the late venous phase, leading to confluent hyperfluorescence and leakage in the late phase, but no choroidal neovascularization was detected (Figure 1E). Choroidal osteoma was diagnosed, and observation was advised. At 6-month follow-up, the best-corrected visual acuity in the affected eye decreased to 20/30. Fundus examination showed that the choroidal osteoma increased in size to 6.0 mm 3 6.0 mm in base diameter (Figure 2A). Tumor thickness remained at 2.0 mm. These findings caused parental pressure and a standard fluence PDT, a standard fluence PDT (600 mW/cm2 intensity) was administered after an intravenous infusion of verteporfin (6 mg/m2). The lesion was treated with three spots. The day after PDT, best-corrected visual
C
horoidal osteoma is a rare intraocular tumor characterized by the presence of bone in the choroid. The tumor is usually diagnosed in the second or third decade of life although it can be seen in children as well.1 Growth is seen in 40% and choroidal neovascularization in 33% of cases. Tumor decalcification can occur spontaneously or can be induced by laser photocoagulation or photodynamic therapy (PDT). Decalcification minimizes further growth to the fovea.2–4 We report a case with subfoveal choroidal osteoma that developed subretinal hemorrhage after PDT. The authors have no conflicts of interest to disclose. Reprint requests: Melis Palamar, MD, Ege Universitesi Tip Fakultesi Hastanesi, Goz Hastaliklari AD, 35040 Bornova, Izmir, Turkey; e-mail: [email protected]
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Fig. 1. A, Fundus photograph of the left eye showing subfoveal choroidal osteoma measuring 5.0 mm 3 4.5 mm in base. B, B-mode ultrasonography of the choroidal osteoma showing a 2.0-mmthick tumor with acoustic solidity, high echogenicity consistent with calcium, and posterior orbital shadowing. C, Orbital computed tomography showing the presence of calcification in the left eye. D, Optical coherence tomography of left eye showing absence of subretinal fluid overlying the tumor. E, Latephase fluorescein angiogram of the left eye showing hyperfluorescence and leakage over the lesion.
acuity in the left eye was found to be counting fingers at 1 m. On fundus examination subretinal hemorrhage over the lesion was detected (Figure 2B). Optical coherence tomography revealed high subretinal reflectivity and loss of foveal contour, consistent with the
Fig. 2. A, Fundus photograph 6 months after the initial examination showing that the choroidal osteoma showed increase from its initial base diameter. B, Fundus photograph 1 day after PDT demonstrating subretinal hemorrhage over the lesion. C, The OCT of the left eye 1 day after PDT showing high subretinal reflectivity and loss of the foveal contour. D, Optical coherence tomography of the left eye 2 weeks after PDT demonstrating resolution of the subretinal hemorrhage and the normal foveal contour. E, Fundus photograph 2 weeks after PDT showing complete resolution of the subretinal hemorrhage. OCT, optical coherence tomography.
clinically observed subretinal hemorrhage (Figure 2C). One week after PDT, the subfoveal hemorrhage started to dissolve and bestcorrected visual acuity increased to 20/50. Two weeks after PDT, subfoveal hemorrhage dissappeared with some retinal pigment
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epithelial hyperplasia (Figure 2, D and E). Best-corrected visual acuity increased back to 20/30.
Discussion Vision loss in choroidal osteoma might develop from photoreceptor degeneration, subfoveal fluid, and subfoveal hemorrhage from choroidal neovascularization. Visual acuity is better in cases without foveal involvement.2 There is insufficient information in the literature about PDT in choroidal osteomas. Shields et al4 reported that PDT can be used in extrafoveal choroidal osteoma to induce decalcification and prevent growth to the fovea. They pointed out that these results should not be extrapolated to subfoveal osteomas. On the basis of the experiences gained from this case, we conclude that PDT should not be used in subfoveal osteomas unless there is compelling evidence to treat the lesion such as the presence of choroidal neovascularization. The reasons against doing PDT in subfoveal osteomas are threefold. First, PDT induces decalcification of subfoveal choroidal osteoma, which can result in vision decrease because of retinal pigment epithelial loss. Second, PDT is known to cause inflammation, ischemia, and vascular endothelial growth factor increase in the retina, which
may trigger subretinal hemorrhage via angiogenesis and increased vascular permeability, as in our case.5,6 Third, choroidal ischemia can develop after PDT of choroidal osteomas, similar to cases with age-related macular degeneration or polypoidal choroidal vasculopathy treated with this modality.5,6 Key words: children, choroidal osteoma, photodynamic therapy, subretinal hemorrhage. References 1. Shields JA, Shields CL. Osseous, myogenic, neurogenic, fibrous, and histiocytic tumors of the uvea. In: Shields JA, Shields CL, eds. Intraocular Tumors. A Text and Atlas. Philadelphia, PA: Saunders; 2008:264–289. 2. Shields CL, Sun H, Demirci H, Shields JA. Factors predictive of tumor growth, tumor decalcification, choroidal neovascularization, and visual outcome in 74 eyes with choroidal osteoma. Arch Ophthalmol 2005;123:1658–1666. 3. Trimble SN, Schatz H. Decalcification of a choroidal osteoma. Br J Ophthalmol 1991;75:61–63. 4. Shields CL, Materin MA, Mehta S, et al. Regression of extrafoveal choroidal osteoma following photodynamic therapy. Arch Ophthalmol 2008;126:135–137. 5. Oh IK, Huh K, Oh J. Risk factors for retinal hemorrhage after photodynamic therapy in age-related macular degeneration. Ophthalmologica 2009;223:78–84. 6. Matsushita S, Naito T, Takebayashi M, et al. The prognosis of cases with massive subretinal hemorrhage after photodynamic therapy. J Med Invest 2008;55:231–235.
