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 Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 29  |  Issue : 3  |  Page : 237-239

Antivascular endothelial growth factor in treatment of choroidal osteoma not associated with choroidal neovascular membrane


Vitreo-retina services, Little Flower Hospital, Angamaly, Kerala, India

Date of Web Publication30-Jan-2018

Correspondence Address:
Dr. Remya Mareen Paulose
Little Flower Hospital, Angamaly, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/kjo.kjo_79_17

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  Abstract 


To report the case of a 52-year-old female with recent complaint of decreased vision associated with a well-defined depigmented lesion in the macula in the right eye. She had a history of surgery for pituitary microadenoma and breast lump excision. Based on spectral-domain optical coherence tomography, fundus fluorescein angiography, indocyanine green angiography, and B-scan ultrasonography, a diagnosis of the right eye choroidal osteoma was made. Subretinal fluid (SRF) was noted in the absence of obvious classic choroidal neovascularization (CNV). The patient was given monthly intravitreal ranibizumab injection over 3 months. Visual acuity was 20/80 preinjection, which dramatically improved to 20/20 after the injections without any additional treatment. We report an interesting case where SRF was noted in the absence of evident CNV and that antivascular endothelial growth factor can be considered as an effective option even in the absence of an evident CNV.

Keywords: Antivascular endothelial growth factor, choroidal osteoma, choroidal neovascularization, ranibizumab, subretinal fluid


How to cite this article:
Cherian T, Paulose RM, Reesha K R. Antivascular endothelial growth factor in treatment of choroidal osteoma not associated with choroidal neovascular membrane. Kerala J Ophthalmol 2017;29:237-9

How to cite this URL:
Cherian T, Paulose RM, Reesha K R. Antivascular endothelial growth factor in treatment of choroidal osteoma not associated with choroidal neovascular membrane. Kerala J Ophthalmol [serial online] 2017 [cited 2018 Sep 19];29:237-9. Available from: http://www.kjophthal.com/text.asp?2017/29/3/237/224298




  Introduction Top


Choroidal osteoma was first described by Gass in 1978 as a slightly elevated, yellowish, juxtapapillary, choroidal tumour with sharp geographic borders.[1] These tumours demonstrate the evidence of bone formation in the choroid. Majority of patients with choroidal osteoma maintain good vision. As reported by Shield's etal, the probability of loss of visual acuity (20/200 or worse) was more than 50% by 10 years in these patients.[2] Choroidal neovascularization (CNV) is the most frequent cause of visual loss in choroidal osteoma. However, the occurrence of subretinal fluid even in the absence of CNV has been reported earlier.[3] The choice of treatment in such a condition is often debatable. In this report we demonstrate a symptomatic case of choroidal osteoma with subretinal fluid, successfully managed with anti- vascular endothelial growth factor alone.


  Case Report Top


A 52-year-old female was referred to the retina department with recent-onset defective vision of 3-week duration. She gave a history of neurosurgery for pituitary microadenoma in 2000 and breast lump excision in 2004. There was no history of radiotherapy or chemotherapy. Visual acuity at a presentation was 20/28, N8 in the right eye and 20/20, N6 in the left eye. Anterior segment evaluation and applanation tonometry were normal in both eyes. Fundus evaluation revealed a well defined orange lesion at the macula with overlying pigmentary changes in the right eye as shown in [Figure 1]a and left eye was within normal limits [Figure 1]b. Spectral domain optical coherence tomography (OCT) (Cirrus HD OCT 5000) revealed dome shaped elevation of choroid with overlying subretinal fluid [Figure 2]a and fluorescein angiography showed central retinal hyperfluorescence with no evidence of pinpoint leakage or late phase leakage [Figure 4]a. Indocyanine green angiography reveals hypofluorescence corresponding to the lesion [Figure 4]b. B scan showed a characteristic elevated choroidal lesion of high reflectivity which persisted on low gain and acoustic shadowing was also noted as shown in [Figure 3]. Thus, a final diagnosis of the right eye choroidal osteoma was made.
Figure 1: Fundus photograph of the right eye shows a well-demarcated yellow-to-orange lesion in the macula. (b) Left eye fundus – normal

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Figure 2: Optical coherence tomography of right eye shows accumulation of subretinal fluid overlying the elevated choroid as shown in (a). Final visit optical coherence tomography showing complete resolution of subretinal fluid (b)

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Figure 3: B-scan of the right eye, with white arrow indicating the site of choroidal osteoma

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Figure 4: Fundus fluorescein angiography of the right eye before injection (a), showing stippled hyperfluorescence in the area of choroidal osteoma and corresponding hypocyanus seen in indocyanine green angiography (b)

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As the patient had a positive history for malignancy, a whole-body positron emission tomography scan was done which showed no evidence of any malignancy. In view of SRF overlying the osteoma and the current drop in vision, she was advised intravitreal ranibizumab injection (0.5 mg in 0.05 ml). On follow-up, her right eye vision improved to 20/40. Subsequently, she received two more monthly doses of ranibizumab. At the final visit, her vision improved to 6/6, N6 and with complete resolution of SRF on OCT as shown in [Figure 2]b.


  Discussion Top


Choroidal osteoma is a benign ocular tumor of unknown etiology characterized by the presence of cancellous bone within the choroid.[4] It typically presents as a unilateral lesion in 75% of cases and commonly in healthy females in their second or third decades of life.[1],[5],[6],[7] It is believed to be a benign choristoma replacing normal choroid with mature bone having bone marrow spaces filled with connective tissue and vessels. Clinically, they appear as irregular, slightly elevated, yellow-white, juxtapapillary, or peripapillary choroidal mass with well-defined geographic borders, with depigmentation of the overlying pigment epithelium. Overlying spider-like vessels may be seen. Patients are usually asymptomatic at detection, and the lesion is found incidentally. However, in those cases where symptoms are present, the patient describes visual loss, metamorphopsia, and/or scotomas. Visual morbidity in choroidal osteoma is a consequence of macular location of the tumor, development of choroidal neovascularization (CNV) or serous detachment, decalcification, and overlying retinal pigment epithelium (RPE) atrophy.[3],[8],[9]

The diagnosis of choroidal osteoma is mainly clinical. Ancillary diagnostic tests include fluorescein angiography, autofluorescence, ultrasound imaging, magnetic resonance imaging, and OCT. Due to the presence of calcified components, choroidal osteomas have high acoustic reflectivity and prominent posterior shadowing or a “pseudooptic nerve.”

Differential diagnoses of yellow subretinal lesions included idiopathic sclerochoroidal coalification, amelanotic choroidal melanoma, amelanotic choroidal nevus, metastatic choroidal carcinoma, and choroidal hemangioma. However, its distinct clinical and ultrasonographic presentation aids in the diagnosis.

SRF collection occurs in eyes with choroidal osteoma frequently even in the absence of CNV. In fact, only about 23% of eyes with SRF have concomitant CNV.[7] It is speculated to be the result of multiple pinpoint RPE leakage sites over the osteoma as detected by fluorescein angiography.[5] Alternatively, atrophy of the RPE and Bruch's membrane is thought to decrease their capacity to remove SRF emanating from the disrupted outer blood–retinal barrier. Although anecdotal reports have mentioned antivascular endothelial growth factor (VEGF) for the treatment of SRF in choroidal osteoma without CNV,[8] the exact mechanism is yet to be understood. In this case, we report the successful treatment of non-CNV-related SRF in a case of choroidal osteoma. It can be concluded that treatment is indicated in a case of SRF in choroidal osteoma even when CNV is absent and that anti-VEGF is an effective option for the resolution of SRF.

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.
Shields CL, Shields JA, Augsburger JJ. Choroidal osteoma. Surv Ophthalmol 1988;33:17-27.  Back to cited text no. 2
    
3.
Najafabadi FF, Hendimarjan SM, Zarrin Y, Najafabadi MF. Intravitreal Bevacizumab for Management of Choroidal Osteoma without Choroidal Neovascularization. Journal of Ophthalmic & Vision Research 2015;10:484-6.  Back to cited text no. 3
    
4.
EmpeslidisT, Imrani U, Konidaris V, Mushtaq F, Fotiou P, Kumar P, et al. Diagnosis and monitoring of choroidal osteoma through multimodal imaging. Case Rep Med 2014;2014:393804.  Back to cited text no. 4
    
5.
Kadrmas EF, Weiter JJ. Choroidal osteoma. Int Ophthalmol Clin 1997;37:171-82.  Back to cited text no. 5
    
6.
Williams AT, Font RL, Van Dyk HJ, Riekhof FT. Osseous choristoma of the choroid simulating a choroidal melanoma. Association with a positive 32P test. Arch Ophthalmol 1978;96:1874-7.  Back to cited text no. 6
    
7.
Aylward GW, Chang TS, Pautler SE, Gass JD. A long term follow up of choroidal osteoma. Arch Ophthalmol 1998;116:1337-41.  Back to cited text no. 7
    
8.
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;123:1658-66.  Back to cited text no. 8
    
9.
Kubota Taniai M, Oshitari T, Handa M, Baba T, Yotsukura J, Yamamoto S. Long term success of intravitreal bevacizumab for choroidal neovascularization associated with choroidal osteoma. Clin Ophthalmol 2011;5:1051-5.  Back to cited text no. 9
    


    Figures

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



 

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