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 Table of Contents  
CASE REPORT
Year : 2016  |  Volume : 28  |  Issue : 2  |  Page : 145-147

Choroidal osteoma: An atypical case


Department of Vitreoretinal Surgery, Dr. Tony Fernandez Eye Hospital, Aluva, Kerala, India

Date of Web Publication20-Mar-2017

Correspondence Address:
Anu Paul
Department of Vitreoretinal Surgery, Dr. Tony Fernandez Eye Hospital, Aluva - 683 101, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/kjo.kjo_4_17

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  Abstract 


A case of choroidal osteoma in a 20-year-old male diagnosed incidentally following dilated fundus examination is reported. The lesion was yellowish-orange in color with well-defined scalloped margins, present in the macular region above the inferior arcade, involving the fovea. Visual acuity was not affected, and there was complete absence of subjective symptoms in the eye. B-scan ultrasonography revealed findings consistent with a choroidal osteoma. Optical coherence tomography showed no retinal edema, retinal thinning or choroidal neovascular membrane. We report this case of choroidal osteoma with atypical presentation in a male and no visual involvement in spite of its location in the posterior pole involving the fovea.

Keywords: Choroidal osseous choristoma, choroidal osteoma, choroidal tumor


How to cite this article:
Paul A, Mani LS, Ramesh R, Shahi A A. Choroidal osteoma: An atypical case. Kerala J Ophthalmol 2016;28:145-7

How to cite this URL:
Paul A, Mani LS, Ramesh R, Shahi A A. Choroidal osteoma: An atypical case. Kerala J Ophthalmol [serial online] 2016 [cited 2019 Nov 12];28:145-7. Available from: http://www.kjophthal.com/text.asp?2016/28/2/145/202480




  Introduction Top


Choroidal osteoma is a benign tumor of unknown etiology which was first described by Gass et al. in 1978. It is typically found in healthy young women, mostly unilateral, in the posterior pole of the eye near the optic disc, and becomes clinically apparent when it involves the macula.[1] Though present from birth, it is usually diagnosed during the second or third decade of life. The diagnosis of choroidal osteoma is based on its very characteristic clinical picture, ultrasonography, and fundus fluorescein angiography findings. This case report depicts a unique case of choroidal osteoma in a young male patient with no visual symptoms even with a large posterior pole lesion involving the macula.


  Case History Top


A 20-year-old male immigrant manual laborer presented to the outpatient department of our hospital with complaints of redness, pain, and watering of right eye following getting hit with a stone 1 day ago. He did not give any past history of ocular symptoms or reduced vision. There was no history of systemic illness. He was not on any regular medication.

The patient had tender lid edema in the right eye, best corrected visual acuity was 6/18, N6 in right eye, and 6/6 N6 in the left eye. The injured right eye had a medial lid tear not involving the margin as well as conjunctival tear laterally, both of which were sutured. Cornea was clear, anterior chamber was normal in depth, cells 3+ with 2 mm hyphema. The dilated fundus examination showed Berlin's edema in the injured eye [Figure 1]. Incidentally, a large yellow orange flat choroidal lesion was noticed in the macular region above the inferior arcade in the contralateral eye (OS) [Figure 2]. The lesion had well-defined and scalloped margins, and measured approximately five disc diameter in horizontal extent, involving the fovea.
Figure 1: OD fundus photograph showing Berlin's edema

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Figure 2: OS fundus photograph showing a posterior pole choroidal osteoma involving the macula

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B scan ultrasonography of the left eye showed slightly elevated choroidal mass with high reflectivity and acoustic shadowing giving a pseudo-optic disc appearance, which was suggestive of choroidal osteoma [Figure 3]. Optical coherence tomography (OCT) of the left eye showed no retinal edema, retinal thinning, or choroidal neovascular membrane (CNVM) [Figure 4]. OCT of the right eye showed disruption of retinal layers with subretinal fluid in the fovea [Figure 5].
Figure 3: Bscan OS showed slightly elevated choroidal mass with high reflectivity and acoustic shadowing

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Figure 4: OCT OS: no retinal edema, retinal thinning, or CNVM

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Figure 5: OCT OD showing disruption of retinal layer with subretinal fluid

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The hyphema and anterior chamber reaction in the injured eye was managed conservatively with topical cycloplegic, steroids, and antibiotic medications. Because the patient had no vision loss and was asymptomatic, no active intervention was needed; he was counselled and advised regular follow-up for the choroidal osteoma in the left eye.


  Discussion Top


Choroidal osteoma is an extremely rare benign tumor of the choroid composed of mature bone. Although it is typically found in healthy young females in the second or third decades of life, few cases have been reported among males and children.[2] It generally occurs as a sporadic trait.

Mostly, choroidal osteomas are asymptomatic. When symptoms are present they include mild to severe visual blurring, metamorphopsia, and visual field defects corresponding to the location of the tumor. It is unilateral in approximately 75% of the reported cases.[3]

Gass et al. in 1978 first described four healthy young women with characteristic ophthalmoscopy appearance of a slightly elevated, juxtapapillary, yellowish orange, choroidal lesion with well-defined margins.[1] It may extend into the macular region. Choroidal osteoma appears as yellow-white to orange-red in color. The shape of the tumor is generally oval or round with characteristic well-defined scalloped or geographic margins. The margins can have blunt pseudopod-like projections. The vasculature within the choroidal osteoma is sometimes visible. Tufts of short branching vessels that originate deep within the tumor and emerge on to the tumor surface can be seen.[2] There are case reports of atypical presentation of choroidal osteoma with elevated juxtapapillary lesions producing diagnostic dilemma.[4]

The mass is composed of dense bony trabeculae with endothelial-lined large cavernous spaces and small capillary blood vessels. Osteoblasts, osteocytes, and osteoclasts are present. Overlying retinal pigment epithelium is focally depigmented and flat in some areas, whereas clumps of pigment granules within melanophages are seen along Bruch's membrane in other areas.

The pathogenesis of choroidal osteoma is unknown. The speculated pathogeneses include possible choristomatous, inflammatory, traumatic, hormonal, metabolic, environmental, or hereditary etiology.[5] Case report of de-novo appearance of a choroidal osteoma in an eye, following years after laser photocoagulation for BRVO (Branch Retinal Vein Occlusion) has been reported.[6] Choroidal osteoma resembles a choristoma in its tissue composition, its apparent onset in youth, and the absence of other preceding ocular disease processes. Features that are atypical for a choristoma are sexual preponderance in females and new development and growth of the tumor during adulthood.[7]

Differential diagnosis include amelanotic choroidal melanoma, amelanotic choroidal nevus, metastatic carcinoma to the choroid, circumscribed choroidal hemangioma, disciform macular degeneration, posterior scleritis, idiopathic sclerochoroidal calcification, and choroidal cartilage.[8]

The most important complications of the tumor are subretinal neovascularization, subretinal and intraretinal hemorrhages, and serous and hemorrhagic retinal detachments.[9]

There is no currently known method for altering the growth of the choroidal osteoma. Periodic ocular examination is recommended. Close examination for the presence of subretinal neovascularization is necessary. Recently, a few reports have described a successful treatment of subretinal neovascularization with intravitreal injections of anti-VEGF agents.[10]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Gass JD, Guerry RK, Jack RL, Harris G. Choroidal osteoma. Arch Ophthalmol 1978;96:428-35.  Back to cited text no. 1
    
2.
Madhusmita B, Manmath KD. A case of choroidal osteoma in a 10-year-old child. Int Med Case Rep J 2015;8:273-5.  Back to cited text no. 2
    
3.
Stephen JR. Retina. In: Carol LS, Gary CB, Sanjay S, Jerry AS, editors. Choroidal Osteoma. 4th ed. Philadelphia: Elsevier; 2006. pp. 819-28.  Back to cited text no. 3
    
4.
Cennamo G, Iaccarino G, de Crecchio G, Liguori G. Choroidal osteoma: An atypical case. Br J Ophthalmol 1990;74:700-1.  Back to cited text no. 4
    
5.
Carol LS, Jerry AS, James JA. Choroidal Osteoma. Surv Ophthalmol 1986;33:17-27.  Back to cited text no. 5
    
6.
Adhi M, Bryant JS, Alwassia CA. De novo appearance of a choroidal osteoma in an eye with previous branch retinal vein occlusion. Ophthalmic Surg Lasers Imaging Retina 2013;44:77-80.  Back to cited text no. 6
    
7.
Shields CL, Shields JA, Augsburger JJ. Choroidal osteoma. Surv Ophthalmol 1988;33:17-27.  Back to cited text no. 7
    
8.
Nick B, Richard AL, Stephen LM. Choroidal Osteoma. AJNR Am J Neuroradiol 1983;4:491-4.  Back to cited text no. 8
    
9.
Ramzi MA, Ahmad MM, Eman K. Review of Choroidal Osteomas. Middle East Afr J Ophthalmol 2014;21:244-50.  Back to cited text no. 9
    
10.
Guruprasad SA, Neeraj P, Vandana D. Choroidal osteoma with CNVM - Successful treatment with intravitreal Bevacizumab. Saudi J Ophthalmol 2011;25:199-202.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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